Mohs Mapping in the Cloud: An Innovative Method for Mapping Tissue in Mohs Surgery

In an article published in 1999, Ratner and Colleagues stated that “Digital photography is transforming the specialty of dermatology, and the World Wide Web will serve as the medium by which these images will reach patients and physicians”.¹ It seems that dreams do come true. Since the introduction of digital photography at the end of the 1990s, digital photographic mapping has slowly become a useful tool to the Mohs surgeon in the clinic and the operating room. Fifteen years ago, we described the first digital computerized Mohs maps in Mohs surgery.² At a survey done between members of the American College of Mohs surgery in 2003, only 1.3% used digital photography to map tissue.3 Since then, with the evolution of computing and internet along with the development of tablets and smart phones, digital photography has been serving the dermatologist and the Mohs surgeon in daily practice. However, few publications have been dedicated to the subject.^2,4,5 Digital photography is used to take pre- and post-operative pictures, to locate biopsy sites in order to avoid operations on wrong sites,⁶ and to transfer information between the referring dermatologist and the Mohs surgeon.

Digital photographic mapping in Mohs surgery requires the use of either single-lens reflex cameras (SLR) or pocket cameras in the operating rooms. The digital map is transferred to the computer in the laboratory via direct connection of the card to the computer.

Recently, using the new technology of storing information in the cloud, we develop a digitalized photographic Mohs mapping in the cloud.

A dedicated cloud was created for the Mohs unit. In our case, it was created in Google apps (Google drive). The digital photographic map in each operating room was taken with either a Samsung or LG tablet (Figure 1a and 1b). Before saving the map in the cloud, the JPG number of the Mohs map was changed to the patient’s first name or patient’s code to protect the patient’s privacy. The map was then saved in the dedicated cloud that was created (Figure 2). Each tablet was left at the operating room. Upon transfer of the tissue on a Telfa non-adherent pad to the Mohs lab, the map was already downloaded to the Mohs laboratory’s computer by the technician, a process that takes no more than 2 minutes. The map downloaded from the cloud was converted into a computerized map by the Mohs technician using either Microsoft PhotoDraw or Photoshop software (Figure 3). If an additional stage was needed, the positive margins were marked in the computer on the computerized map. The map was then uploaded to the cloud. The Mohs surgeon is able to view the map immediately on the tablet in the operating room. All Mohs maps are stored in the cloud in a dedicated category (Figure 4). The entire process is schematically described in Figure 5.

With the evolution of electronic medical records and the increased usage of tablets in medical clinics and departments, the utilization of Mohs maps, either drawn or template-based, becomes almost anachronistic. The aim of achieving the paperless office is reaching medical clinics and operating theaters. This need also applies to MMS. Pre- and post-operative digital