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Mohs micrographic surgery (MMS) has become the standard of treatment for skin malignancies of the head and neck. However, there is a paucity of literature describing facial distributions of MMS. Anatomical location of skin cancer is an important feature to study as it can affect prognosis as well as pathogenesis of skin cancers. This study aims to analyze consistency in head and neck MMS anatomical distributions and compare differences between multiple centers. The study retrospectively reviews 5871 MMS cases performed at a single center in Chevy Chase, Maryland from January 2014 through December 2019. Results show distributions of skin cancers on the face treated with MMS consistently occur at the same anatomical sites year after year with minimal variance. This knowledge of consistency provides a foundation for future studies because it allows for comparison. Comparing and contrasting data across multiple centers can elucidate regional characteristics that may impact the pathogenesis and distribution of facial skin tumors. Many regional or demographical factors may be important in the development of cutaneous malignancies. This information should be considered when assessing risk factors for cancerous skin lesions.J Drugs Dermatol. 2022;21(5):506-509. doi:10.36849/JDD.6143.

Background: At the onset of the COVID-19 pandemic, many Mohs micrographic surgeries (MMS) were delayed over concerns for propagating further infectious spread and scarcity of medical resources., Objective: To assess the impact of the pandemic on MMS and the treatment of skin cancer Methods and Materials: An electronic survey was sent to fellowship trained Mohs surgeons to assess patient outcomes, practice viability, and physician sentiment related to performing MMS during the COVID-19 pandemic., Results: Of the 303 respondents, 82% reported declines in case volume for at least 3 months, and average case difficulty increased for 69% of surgeons following these delays. Instances of local tumor spread following delays were seen by 69% of respondents, and 20% noted cases of regional or systemic metastasis. Only 8 cases of staff testing positive (and 7 cases of patients) were reported, and 97% of respondents felt comfortable performing MMS during the pandemic. Private practice surgeons more often viewed practice restriction recommendations negatively initially (42% vs 26% in academics, P=0.03) and in hindsight (63% vs 36% in academics, P<0.001)., Conclusions: Mohs surgeon’s ability to minimize spread of COVID-19 during routine patient care, alongside potential risks of delaying treatment of skin cancers, should be considered in future recommendations for patient care. J Drugs Dermatol. 2022;21(5):545-547. doi:10.36849/JDD.6189.

As the incidence of non-melanoma skin cancer (NMSC) increases in the United States, one area of particular concern is NMSC arising on the genitalia. In the past, most genital skin tumors have been treated by conventional radical surgical approaches such as penectomy, vulvectomy, or wide local excision. In recent years, tissue sparing Mohs micrographic surgery (MMS) has been established as a safe and effective method of achieving cutaneous genital tumor clearance. The aim of this article is to provide an overview of NMSCs arising on genital skin treated with MMS, and describe some of their indications, results, and associated complications. A summary of case reports, case series, and retrospective reviews is made available to guide decision making and surgical planning for tumors of this nature. Pertinent anatomy, site-specific surgical techniques, and reconstruction options of genital skin will be discussed. J Drugs Dermatol. 2021;20(3):311-319. doi:10.36849/JDD.5656.

In 1999, the Institute of Medicine’s (IOM) first report, “To Err Is Human”, brought forth the issue of medical error in patient care.1 In this publication, the IOM recognized that mistakes or failures to prevent mistakes were mostly caused by flawed systems, processes, and conditions. It outlined a four-tiered approach to improve safety including: 1) development of leadership, research, tools, and protocols to enhance the knowledge base on safety, 2) a nationwide public mandatory reporting system and encouraging voluntary participation to identify and learn from errors, 3) oversight organizations, professional groups, health care purchasers to raise performance standards and expectations, and 4) implementation of safety systems in the healthcare organization to ensure delivery of safe practice. This was the first roadmap towards a safer health system.

Perineural invasion (PNI) is associated with high risk keratinocyte carcinomas. Identification of PNI during Mohs surgery is important for staging and post-adjuvant treatment decisions but can be challenging. To confirm or exclude PNI suspected on hematoxylin and eosin sections, we performed immunohistochemical double staining on Mohs frozen sections. Neural marker SOX10 and pan-cytokeratin marker AE1/AE3 were combined in a simultaneous assay using species-specific (mouse and rabbit) antibodies and horseradish peroxidase and alkaline phosphatase detection systems. Of 23 Mohs cases with suspected PNI, 18 were confirmed to have definitive nerve involvement by tumor using double staining. Double staining frozen tissue is feasible and can be beneficial for real time confirmation of PNI during Mohs. J Drugs Dermatol. 2019;18(3):262-264.

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.

Background: Between stages of Mohs micrographic surgery, the wound is dressed and the patient waits for the histopathological results.
, Objective: To investigate the efficacy of a hemostatic-anesthetic solution-impregnated gauze in decreasing bleeding between Mohs stages.
, Materials and Methods: Twenty patients were treated with a hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL), and 20 others were treated with a saline solution for control. At the second Mohs stage, size measurements of the blood stain on a Telfa pad and the defect were recorded. The Rotation Thromboelastometry Method (ROTEM) was used to investigate a possible effect of lidocaine and adrenaline on the clot stability induced by tranexamic acid.
, Results: The ratio of blood stain size to Mohs defect size in the hemostatic anesthetic solution group was 1:1.47, whereas the ratio in the control saline group was 1:3.37 (P&lt;.001). Results of the ROTEM test showed that lidocaine and adrenaline did not interfere with the effect of tranexamic acid on clot formation and stability.
, Conclusion: The application of gauze impregnated with tranexamic acid, adrenaline, and lidocaine on a surgical wound may be effective in reducing bleeding between Mohs stages. , , J Drugs Dermatol. 2016;15(7):851-855.

Background: Mohs micrographic surgery (MMS) is the most useful surgical method for the treatment of skin cancer. One of the key factors in MMS is the mapping of the excised tissue in relation to its original location. Since the introduction of MMS, mapping has been modified from simple drawing to digital photographic maps., Method: Maps during MMS were taken using Samsung and LG tablets. The maps were saved to the cloud in the operating rooms. A short time after, the maps were downloaded to the laboratory's computer by the Mohs technician and processed to a digital photographic map. When additional stage was needed, the map was uploaded by the technician to the cloud and viewed by the Mohs surgeon on the tablet in the operating room., Conclusion: Mohs mapping on the cloud is a new method of mapping tissue in MMS. It is an easy, fast, and accurate method of mapping and serves the new era of modern web and photographic technologies.

Background: Vismodegib, a hedgehog pathway inhibitor has been recently introduced as an oral therapy for locally advanced and metastatic basal cell carcinoma. Although treatment of patients with basal cell carcinoma with vismodegib has been associated with partial or complete clinical response, it is still unclear if it is also associated with histological cure., Patients: Two patients with 3 large and aggressive basal cell carcinomas were treated with Vismodegib for 6 months. The treatment was followed by Mohs micrographic surgery., Results: Two tumors disappeared clinically and one was reduced dramatically in its size following treatment with vismodegib. Mohs surgery in all three tumors revealed residual islands of BCC although margins were cleared at the end of surgery., Conclusions: Neoadjuvant therapy with vismodegib for 6 months prior to Mohs surgery was effective in reducing the size of primary and recurrent aggressive basal cell carcinoma. However, residual tumor nests were found during surgery. Further larger studies are needed to evaluate the efficacy of Vismodegib as a neoadjuvant treatment prior to Mohs surgery.

Dermatofibrosarcoma protuberans is a rare, slow growing tumor. This growth occurs most frequently in males from ages 20 to 50. The most common area on which DFSP originates is the trunk. DFSP presents clinically as a pink nodule or as a firm, flesh-colored to brown, indurated and exophytic plaque. Pathology shows atypical spindle cells of fibroblast origin surrounding a core of collagen. The definitive treatment of DFSP is surgical excision. Imatinib is a tyrosine kinase inhibitor that has been approved for use in DFSP refractory to surgery.

Microscopic frozen section interpretation is one of the cornerstones of Mohs surgery. The recent development of super wide field (SWF) microscopy can improve accuracy and efficiency while reading microscope sections, and also decrease the physician's musculoskeletal and ocular strain. Super wide field microscopy systems increase viewable field area (VA) by combining low magnification objectives, eg, 1x or 2x (Figure 1), with eyepieces that have a higher field number. This article reviews 3 SWF microscopy systems: Leica DM2000 (Leica Microsystems, Wetzlar, Germany), Nikon Eclipse Ni (Nikon Instruments Inc., Melville, NY), and Olympus BX43 (Olympus, Center Valley, PA). The Leica DM2000's 1.25x objective results in a VA of 314.16 mm2. The Nikon Eclipse Ni's 1x objective results in a VA of 490.87 mm2. The Olympus BX43's 1.25x objective results in a VA of 352.99 mm2. The maximum VA at the lowest objective for Nikon is nearly 40% greater than for the Olympus and over 50% greater than for the Leica. The Nikon Eclipse Ni has a significantly higher maximum VA than the other 2 systems.

Basal cell carcinoma (BCC) is the most common cutaneous malignancy, and usually presents on sun-exposed areas of the skin. Unsurprisingly, BCC appearing on the nipple-areola complex (NAC) is rare, and even more so in females and dark skin types. BCC of the NAC is more aggressive than other locations, thus diagnosis and treatment are imperative. We present a case of an African American female with a lichenified, scaly plaque on her left areola that was unresponsive to clobetasol. After biopsy, the lesion was identified as pigmented BCC of the NAC. The patient denied surgical treatment and was treated with topical 5-fluorouracil. The BCC initially resolved but recurred at 22 month follow-up. We plan to treat the recurrence with Mohs surgery.

Biobrane is a biosynthetic wound dressing that has been widely used in burn treatment and as a skin graft donor site dressing. Our aim for this review was to establish whether Biobrane serves as a useful tool for the field of Dermatology and Dermatologic surgery. It has been frequently used in the field of Dermatology for the management of burns, erosive skin diseases, laser procedures, and surgical procedures. From the past experiences evident in the literature and in our cases series, it has been shown to improve patient's quality of life by reducing pain, healing time, and length of hospital stay. Our case series further demonstrate its use in temporary closures, delayed reconstructions, and secondary intention healing in Mohs surgery. Reports of successful use of Biobrane in the literature and in our case series support the fact that it is an effective therapeutic option to facilitate the healing process in the field of Dermatology and Dermatologic surgery.

Basal cell carcinoma (BCC) is the most common cancer in the world. It is typically slow growing and usually effectively managed with surgery. However, BCCs in some patients are unsuitable for surgery or the patient may prefer a nonsurgical treatment. Radiotherapy is a nonsurgical option for the primary treatment of either low- or high-risk BCCs. It is associated with high cure rates, albeit somewhat lower than those observed with Mohs micrographic surgery for high-risk BCCs. Not all patients with BCCs are suitable for radiotherapy. Superficial therapies for BCC include topical imiquimod or 5- fluorouracil and photodynamic therapy (PDT). These therapies are generally associated with somewhat lower clearance rates and/or higher recurrence rates than surgery or radiotherapy, although they may be suitable in patients with low-risk BCCs when surgery or radiotherapy are impractical or less appropriate. An appealing feature of PDT is excellent cosmesis, but PDT is not currently approved by the Food and Drug Administration (FDA), and regimens are not well standardized. Vismodegib is a first-in-class hedgehog pathway inhibitor and recent addition to the armamentarium for the treatment of advanced BCC.

Microscopic interpretation represents the central tenet for diagnosis and eradication of cutaneous tumors. Standard microscopes are limited by relatively high-powered objectives and smaller viewable diameter. Newer equipment offers optional lower powered objectives including 1X and 2X objectives and can be combined with super widefield eyepieces to greatly enhance the viewable area during pathologic interpretation of slides. Mohs micrographic surgery represents one of the most useful areas in which the dermatologic surgeon gleans multiple efficiencies from these microscope systems. One such system that was recently trialed, the Nikon 80i microscope, proved to be incredibly easy to use and multiple efficiencies were quickly realized.

Objectives: To determine the effectiveness of HP802-247 compared with bacitracin ointment in healing wounds resulting from Mohs micrographic surgery., Methods: Open-label, randomized pilot study conducted at a single center. Subjects were randomized to either HP802-247 (5M cells/mL) applied weekly or bacitracin ointment applied daily. Treatment continued for up to 12 weeks or complete wound closure. Primary efficacy was effectiveness as measured by the Investigator's Global Assessment of Healing (IGAH) scale. Secondary outcomes included median time to healing, investigator- and subject-scored signs and symptoms, and an assessment of scar by the investigator at 16 weeks postsurgery., Results: All subjects achieved favorable outcomes within the study period; however, these were reached more quickly for the HP802-247 group than for bacitracin. At 3 weeks postsurgery, healing was assessed as very effective for 75% of subjects in the HP802-247 group compared with 50% for bacitracin. Median time to closure was 24.5 days for HP802-247 and 29 days for bacitracin. Scores for signs and symptoms and scar were similar for both groups but, in general, were numerically better for HP802-247., Conclusion: In this small pilot study, HP802-247 was found to provide a modest, incremental benefit in the healing of Mohs micrographic surgery wounds, suggesting that the healing of uncomplicated acute wounds may be slightly accelerated without enhancement of scarring.

An appropriate selection of topical agents for wound care is important to promote uncomplicated healing. Petrolatum-based ointments, such as Aquaphor Healing Ointment (AHO) and white petroleum jelly, are commonly employed to keep wounds moist postoperatively. While they have beneficial properties for wound healing, they also may cause wound redness and swelling. We decided to evaluate for wound reactivity postoperatively for these 2 commonly used petrolatum-based ointments. We found that surgical wounds treated with AHO had a higher incidence of wound redness (52%) than those treated with plain white petrolatum (12%).

Objective: To examine white coat hypertension (WCHTN) in patients presenting for Mohs micrographic surgery (MMS) to determine whether it should be a concern., Methods: In this prospective study, blood pressure (BP) was recorded in 100 consecutive patients who presented for MMS consultation and a subsequent MMS procedure, and compared on both days. Statistical analysis was performed using the paired Student t test and the significance of the findings was determined based on the corresponding P values. Progression from normotensive to hypertensive state while the doctor was in the room was stratified based on the patient's age, gender, and histories of smoking, hypertension (HTN), diabetes, and hyperlipidemia; as well as whether the doctor was wearing a white lab coat over blue surgical scrubs (50 patients) or blue surgical scrubs alone (50 patients)., Results: BP increased from baseline when the doctor entered the room and then decreased towards baseline after five minutes of the doctor being present. Elevation in BP was more evident in younger people, males, and those with HTN and hyperlipidemia. BP was slightly higher on the day of the consultation than on the day of the procedure. A higher number of patients became hypertensive when the doctor wore a white lab coat over blue surgical scrubs vs blue surgical scrubs alone. However, these changes in BP did not prove to be statistically significant., Conclusion: Brief periods of WCHTN were seen on both days. However, these elevations in BP were not statistically significant and decreased towards baseline after five minutes. There were no cases in which elevation in BP associated with WCHTN was sufficient to result in the need to postpone or cancel MMS.

Background: Surgical reconstruction of defects on the lower half of the nose mandates special considerations. Simple excision and suturing might cause a depressed scar and nostril flaring. Hence, the preoperative plan should be designed properly to avoid disfigurement and to achieve a successful reconstruction., Objective: Three basic reconstructive concepts are essentially combined: 1.) The ratio between scar length and defect diameter should be extended beyond the standard 3:1 ratio; 2.) The defect should be positioned asymmetrically within the inferior half of the excision outline; and 3.) Para-median defects mandate an inferior, horizontal advancement ("sliding") flap to avoid nostril flaring. A salvage technique is also discussed., Methods: Data from patients treated by Mohs micrographic surgery for tumors of the inferior aspect of the nasal dorsum and reconstructed according to the proposed course of action was collected and reviewed., Results: The proposed reconstructive path proved successful for all patients. Although one case required salvage skin grafting, all patients had aesthetically pleasing results. No postoperative complications were noted., Conclusions: Simple excision and primary suturing is a viable method for treating lesions on the lower half of the nose, provided that the surgeon follows a set of basic reconstructive principles.

Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

Cutaneous lymphadenoma (CL) is a benign neoplasm commonly presenting on the head and neck of young and middle-aged adults. Complete surgical excision of CL is the treatment of choice and appears to be curative. As compared to local excision without margin control, Mohs micrographic surgery (MMS) may allow for more definitive tumor extirpation for large cases of CL and allow for greater tissue preservation at functionally and aesthetically sensitive sites. We present a case of cutaneous lymphadenoma presenting on the right cheek of a middle-aged male who was successfully treated with MMS.

Mohs micrographic surgery can be unpredictable with respect to the level of difficulty of individual cases, especially when pre-operative information is limited. In a retrospective study, Sahai and Walling found complex tumors as defined by requiring four or more stages to clearance to be associated with: recurrent tumors, basal cell carcinoma (BCC) with aggressive histology, tumors with a pre-operative size greater than 1 cm and tumors on the nose.1 The authors created a simplified system for "triaging" Mohs surgery cases in order to predict case complexity and, thus, be better able to manage the scheduling of those cases. Data gathered from 12 months of utilizing this system was used to validate the system's ability to predict case complexity with respect to number of stages for tumor clearance and complexity of reconstruction.

In recent years, Mohs micrographic surgery (MMS) has become a widely utilized method of removal for a variety of cutaneous neoplasms. Certain clinical scenarios, however, make it difficult to visualize residual tumor cells, potentially decreasing the efficacy of the Mohs procedure. Immunohistochemical (IHC) stains are now available and are being utilized to delineate cells of interest intraoperatively when routinely stained slides are equivocal. While useful, IHC stains have not gained wide acceptance as an adjunct to MMS, particularly due to increased processing time, cost and workload required. There have been multiple recent advances, however, in the utilization of IHC stains in MMS. In this article, the authors discuss recent advances in IHC stains used in MMS for the treatment of melanoma as well as nonmelanoma skin cancers, potentially making their routine use in select cases more feasible.

The advent of rapid immunostains has made the use of Mohs surgery to treat melanoma more practical. Mohs surgery is especially useful in the management of lentigo maligna, which often has indistinct clinical margins. The authors describe their technique for treating melanoma in situ with Mohs surgery.

Background: Eye shields and lubricants are recommended for use in the eye during periorbital surgery to prevent injury to the globe. Nonetheless, data regarding their use is sparse, and no study to date has examined the prevalence of their usage and complications., Purpose: To investigate how commonly eye shields and lubricants are used during periorbital surgery and whether there are complications from their use., Methods: The authors conducted a survey of oculoplastic and Mohs surgery fellowship directors. The questionnaire investigated the prevalence of use of eye shields and lubricants, complications encountered, and whether the standard of care requires or prohibits their use., Results: A majority of those surveyed at least sometimes use eye shields in periorbital surgery, particularly to prevent patient injury. Most surgeons believe there are more pros than cons to their use. However, corneal abrasions may be encountered and may be related to the type of lubricant chosen. Surgeons using fat-based lubricants tended to encounter more complications with eye shield use., Conclusion: Eye shield and lubricant use is common among oculoplastic and Mohs surgeons. However, most disagree as to whether the standard of care requires or forbids their use.

This case report seeks to alert the reader to the possibility that the keratoacanthoma (KA) may develop in tattoo sites, specifically in red tattoo sites. We further wish to describe the senior author's treatment of such a lesion using Mohs micrographic surgery and a rotation flap to preserve the integrity of the original tattoo design in an area of minimal skin laxity. We briefly discuss the etiology of the KA and review potential tattoo reactions as presented in the literature.

Background: Surgical excision, including Mohs micrographic surgery, is the treatment of first choice for basal cell carcinoma (BCC). Occasionally, the Mohs procedure has to be ceased prematurely for unforeseen reasons., Objective: We sought for possibilities to adjuvantly treat patients in which superficial basal cell carcinoma remained after incomplete Mohs surgery., Methods: We report 3 cases of patients in which Mohs micrographic surgery for their large basal cell carcinomas was ceased for different unforeseen reasons, with remaining superficial fields of BCC after the aggressive and deeply localized part had been removed. Three weeks after closure of the defect, adjuvant therapy for the superficial remnants of the tumor with imiquimod 5% cream was given for 6 weeks, covering at least 1 centimeter around the surgically treated area., Results: The treatment was well accepted with no serious side effects and a good cosmetic result. No recurrences were seen after a follow-up period of 20 to 34 months., Conclusion: A combination of surgical intervention for the central deeper part of the BCC and topical imiquimod 5% cream for the superficial part at the border might be a therapeutic option for those patients with multiple facial BCCs, severe sun damage, and extensive surgery in the past, in whom completion of the Mohs surgical procedure for the entire tumor is not possible for different reasons.

Background: Verrucous carcinoma of the foot is a slow-growing tumor that is capable of causing vast local destruction. It is a rare tumor and is frequently misdiagnosed as a plantar wart., Objective: To describe a patient with verrucous carcinoma of the foot treated by Mohs micrographic surgery and give a review of the literature., Results: A 43-year-old male with plantar verrucous carcinoma was successfully treated with Mohs micrographic surgery., Conclusion: Early diagnosis of verrucous carcinoma of the foot and treatment with Mohs micrographic surgery may prevent amputation of the foot.

Background: A common practice is not to operate on patients with elevated blood pressure (BP) levels to avoid cardiovascular and cerebrovascular complications. We therefore designed a study to evaluate the effect of prolonged surgery under local anesthesia on BP levels, and to compare the outcome of patients with elevated BP to those with normal BP., Methods: We studied 121 patients (65 males) with a mean age of 60 ++/-14 years (range 31-89) who were referred for Mohs micrographic surgery (MMS) during 2 consecutive months. Forty six patients had a history of hypertension. Blood pressure was measured in all subjects in the supine position with an automated device 5 times during surgery., Results: Blood pressure decreased significantly during surgery from 152 +/- 2/85 +/- 1 mm Hg at baseline to 139 +/- 2/79 +/- 1 at the end of the surgery (p < .05). Forty two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels at the end of the first stage. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline., Conclusions: Blood pressure levels decrease during MMS under local anesthesia and the outcome of patients with elevated BP is good. Thus, patients with elevated BP can safely undergo surgery under local anesthesia.

High quality frozen sections are fundamental in Mohs surgery, and one of the main elements in tissue processing is the mounting of the specimen. The Miami Special has been used for this purpose at the University of Miami for over 30 years. Since 1989 the Miami Special has languished in the literature among a growing list of mounting instruments. Therefore, new generations of Mohs surgeons may not be acquainted with the advantages of this instrument. This article describes the Miami Special and outlines its use for the benefit of current practitioners.