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Background: As the availability of Mohs micrographic surgery (MMS) continues to expand in Australia and incidence of keratinocyte cancer increases in adolescents and young adults, there has been rising interest in the use of MMS in this population., Objective: This study aimed to evaluate the characteristics of MMS cases in patients younger than 40 years., Methods: A review was performed of all MMS cases in patients younger than 40 years at the time of their surgery from 2012 to 2017 at the Skin and Cancer Foundation Australia, with comparison to a control group, aged older than 40 years. Patient, tumor and management characteristics were analyzed., Results: Four hundred ninety-three cases were eligible. Study and control groups differed significantly regarding gender (p < .001), tumor pathology (p < .001), anatomic site of tumor (p < .001), Mohs surgery stages (p = .039), defect size (p < .001), and repair method (p < .001)., Limitations: Retrospective study at a single institution., Conclusion: Mohs micrographic surgery cases in patients younger than 40 years exhibit unique patient and tumor characteristics influencing choice of repair method.

Penile cancers are rare malignancies. Traditional surgical options, including partial and total penectomy, can dramatically affect a patient's quality of life and mental health. In select patients, penile sparing techniques (PST) have the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual function, and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of the various PST currently available for men seeking an organ-preserving option for their penile cancer.

Background: There are few studies analyzing the surgical site infection (SSI) rate of second intention wounds after dermatologic surgery, and the results are inconclusive. Yet, the current dogma in dermatologic surgery is that wounds healed by second intention have lower infection rates., Objective: To determine the rate of SSI and associated pathogenic organisms of second intention wounds compared with sutured wounds after skin cancer extirpation., Materials and Methods: This was a retrospective cohort study of patients who had either Mohs micrographic surgery or wide local excision (WLE) for skin cancer extirpation between 2012 and 2016. Wounds were stratified by closure type, location, and associated organisms. Infection was diagnosed by a positive wound culture., Results: The overall infection rate was 3.9%. The infection rate for sutured and second intention wounds was 3.2% and 6.8%, respectively. Second intention wounds were associated with a significantly higher risk of infection compared with sutured wounds (odds ratio = 2.22, 95% confidence interval 1.63-2.99). The lower extremity (LE) had the highest overall infection rate (10.5%). The face had the lowest overall infection rate (2.5%)., Conclusion: Mohs micrographic surgery or WLE performed on the LE or lesions allowed to heal by second intention has an increased risk of SSI.

Background: Surgeons use absorbable and nonabsorbable sutures for epidermal wound closure. No large, randomized studies have compared the effect of these suture types on facial scar appearance., Objective: To assess postsurgical facial scar appearance using either rapidly absorbable polyglactin 910 or nylon for epidermal closure., Methods: Randomized, blinded, split-scar clinical trial. A total of 105 patients with facial wounds resulting from Mohs micrographic surgery excisions were randomly assigned for epidermal closure with rapidly absorbable 5-0 polyglactin 910 (Vicryl Rapide) on one half of the repair and 5-0 nylon (Ethilon) on the other half. Two physicians (1 dermatologist and 1 plastic surgeon), unaware of the original suture location, examined photographs of each healed wound at 6 months after surgery and graded the appearance of each half of the scar using the visual analog scale, wound evaluation scale, and Stony Brook Scar Evaluation Scale., Results: At 6 months, there was no significant difference in the combined mean (standard deviation) visual analog scale scores (83.1 [14.2] and 83.0 [13.7]), Stony Brook Scar Evaluation Scale scores (4.3 [0.9] and 4.4 [0.9]), or wound evaluation scale scores (5.3 [1.1] and 5.2 [1.1]) for rapidly absorbable polyglactin 910 versus nylon (P = .72, .57, and .21, respectively)., Limitations: Single institution., Conclusions: Both rapidly absorbable polyglactin 910 and nylon sutures placed through the epidermis resulted in an equivalent photographic appearance of facial scars at 6 months after surgery., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Treatment of keratinocyte carcinomas requires an assessment of the extent of tumor spread. Visual delineation of tumor margins is error-prone owing to the limited contrast between cancerous and normal skin. In this contribution, we introduce spectrally-encoded optical polarization imaging and evaluate its performance for preoperative demarcation of keratinocyte carcinomas. Subjects with basal or squamous cell carcinoma, scheduled for Mohs surgery, were enrolled. The surgeon outlined the clinical boundary of each lesion preoperatively. Optical images of the lesions were then acquired at 440 and 640 nm. Spectral encoding of the experimental images minimized the impact of background pigmentation and vascularization. The surgeon was blinded to the imaging results. Margin assessments by imaging and by the surgeon were recorded and compared with the intraoperative histopathology. In total, 53 lesions were imaged in vivo. Thirteen cases required more than one Mohs stage. In all these cases, images accurately visualized the tumor. For cases negative following the first Mohs stage, margin assessments correlated with histopathology in 39 out of 40 cases. Imaging demonstrated 100% sensitivity and 98% specificity. Spectrally-encoded optical polarization imaging may prove valuable for real-time noninvasive preoperative delineation of skin cancer., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been accompanied by wide variations in practice patterns and a lack of best practice guidelines., Objective: The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate commonalities and variations in their use of MMS to treat melanoma., Materials and Methods: A cross-sectional analysis was performed using survey responses of Mohs surgeons with membership in the American College of Mohs Surgery., Results: A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210 (58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage for MIS was 4.96 ± 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with 145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated with MMS., Conclusion: Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early invasive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use MART-1 when excising invasive melanoma with MMS.

Purpose: The purpose of this study is to investigate the clinical efficacy of Mohs surgery in combination with topical photodynamic therapy (PDT) for facial basal cell carcinoma., Patients and Methods: Eighty-six patients with facial basal cell carcinoma treated in our department from April 2011 to December 2013 were included. Mohs surgery was used to remove the lesions followed by direct suturing, skin flap grafting, or medium thickness free-skin grafting to repair the incisions. Topical PDT was performed three times, at an interval of 2 weeks, immediately after the sutures were removed. The patients were followed up for 2 years after the operation to evaluate tumor recurrence., Results: Recurrence was not observed within 1 year after Mohs surgery combining PDT; however, one case of recurrence was found at the 2-year follow-up., Conclusion: The efficacy of Mohs surgery combining topical PDT is a definite treatment for facial basal cell carcinomas, as it reduced the tumor recurrence rate and maintained the relative integrity of the local tissues and appearance. This method could be a new effective treatment method for the facial basal cell carcinoma., Competing Interests: None

Dermatologic surgeons are at increased risk of contracting SARS-COV-2. At time of writing, there is no published standard for the role of pre-operative testing or the use of smoke evacuators, and personal protective equipment (PPE) in dermatologic surgery. Risks and safety measures in otolaryngology, plastic surgery, and ophthalmology are discussed. In Mohs surgery, cases involving nasal or oral mucosa are highest risk for SARS-COV-2 transmission; pre-operative testing and N95 masks should be urgently prioritized for these cases. Other key safety recommendations include strict control of patient droplets and expanded pre-clinic screening. Dermatologic surgeons are encouraged to advocate for appropriate pre-operative tests, smoke evacuators, and PPE. Future directions would include national consensus guidelines with continued refinement of safety protocols.

Limited data exist comparing staples and sutures for closing scalp wounds during Mohs micrographic surgery (MMS). We surveyed practicing Mohs surgeons who were members of the American College of Mohs Surgery (ACMS) on their scalp wound closure preferences as well as the clinical and economic variables that impact their decisions. Comparisons were made between current practice habits, preferences, and provider demographics. Sixty-eight ACMS fellowship-trained Mohs surgeons completed the survey. Overall, scalp wounds during MMS were most frequently closed using staples.

Background: Successful surgical treatment of cutaneous melanoma is dependent on margin control., Objective: To determine efficacy of modified Mohs micrographic surgery (mMMS) with en face permanent margins in management of invasive melanoma (IM) and melanoma in situ (MIS)., Methods: A retrospective cohort study evaluating local recurrence, 5-year recurrence-free survival, and 5-year melanoma-specific survival. Overall, 657 melanomas (128 IM and 529 MIS) from 631 patients were treated using mMMS during a 10-year period. Follow-up information was obtained from medical records and telephone encounters., Results: The median follow-up time was 5.18 years. Most melanomas were located on the head and neck 93.6% (615/657). Margins required for clearance were 0.77 ± 0.44 cm (mean ± SD). Local recurrence was identified in 1.98% (13/657) of melanomas with no local recurrences in IM. Five-year local recurrence-free and melanoma-specific survival rates were estimated to be 96.9% (95% confidence interval [CI]: 94.6%-98.2%) and 99.0% (95% CI: 97.7%-99.6%). There were 5 melanoma-related deaths., Conclusion: Modified Mohs micrographic surgery is an effective treatment of melanoma as evidenced by low local recurrence rates and high melanoma-specific survival.

Cutaneous head and neck reconstruction following Mohs micrographic surgery frequently presents the surgical dilemma of dog-ear formation during wound closure. Z-plasty corrects a dog-ear deformity without skin excision by recruiting tissue from the axis of the standing cone and redistributing it along another. We describe dog-ear correction using the Z-plasty technique.

Background: Patients are often concerned about the cosmetic appearance of scars following Mohs micrographic surgery (MMS), including residual erythema. However, few studies have compared the cosmetic outcomes between different suturing techniques., Objective: To compare the erythema intensity (EI) associated with interrupted sutures (IS) and continuous sutures (CS), and the degree of its reduction over time., Materials and Methods: Mohs micrographic surgery patients were randomized to have half of their defect repaired with IS and the other half with CS. Postoperatively, subjects were assessed at 1 week, 2 months, and 6 months and close-up photographs of their scars were taken. Computer-assisted image analysis was utilized to quantify the EI in each half-scar., Results: The average EI of IS was greater than that of CS by 9.3% at 1 week (p < .001) and 7.2% at 2 months (p < .021) but comparable at 6 months. These differences were clinically detectable, but EI differences resolved by 6 months in most cases. At 6 months, EI regressed by 33.5% in IS and 26.3% in CS., Conclusion: Continuous sutures are associated with less erythema during early scar maturation but are comparable to IS at 6 months. These results may guide the choice of suturing technique to improve early cosmetic outcomes and overall patient satisfaction.

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare, locally infiltrating, rarely metastasizing, soft tissue tumour. Due to its indistinct margins, local aggressive behaviour and high recurrence rate, the surgical approach is complex. Micrographic surgery and variants of this technique, e.g. Tubingen torte technique (TTT), should be considered as first-line treatment., Objectives: To confirm that TTT is a safe and tissue-sparing technique, relative to theoretical wide local excision (WLE), for the same lesions, as recommended by the guidelines in the literature., Materials and Methods: Seventeen patients with histologically confirmed DFSP, treated with TTT between September 2014 and February 2019, were retrospectively analysed. For each patient, the final TTT excision area was calculated and compared with the theoretical equivalent area based on WLE. The difference in area was calculated and presented as percentage difference of preserved healthy skin based on the two approaches., Results: In our patients, the mean preoperative lesion size was 4.55 ± 5.34 cm 2 . The mean final total excised area was 17.73 ± 11.75 cm 2 for TTT and 53.65 ± 15.57 cm 2 for WLE. The amount of preserved healthy tissue using the micrographic technique was significant; 69.15% (95% CI: 62.95-75.36) of healthy tissue was preserved using TTT. No recurrence or metastases were observed in any of the patients after a median follow-up period of 38.00 ± 21 months., Conclusion: In our experience, TTT remains a safe, effective and tissue-sparing treatment for DFSP patients, especially when it is essential to spare tissue and in challenging locations.

Objective: To provide a formal statistical comparison of the efficacy of melanoma detection among different clinical settings., Methods: A systematic review and meta-analysis of all relevant observational studies on number needed to treat (NNT) in relation to melanoma was performed in MEDLINE. We performed a random-effects model meta-analysis and reported NNTs with 95% confidence intervals (CIs). The subgroup analysis was related to clinical setting., Results: In all, 29 articles including a total of 398,549 biopsies/excisions were analyzed. The overall NNT was 9.71 (95% CI, 7.72-12.29): 22.62 (95% CI, 12.95-40.10) for primary care, 9.60 (95% CI, 6.97-13.41) for dermatology, and 5.85 (95% CI, 4.24-8.27) for pigmented lesion specialists., Limitations: There is heterogeneity in data reporting and the possibility of missing studies. In addition, the incidence of melanoma varies among clinical settings, which could affect NNT calculations., Conclusion: Pigmented lesion specialists have the lowest NNT, followed by dermatologists, suggesting that involving specialists in the diagnosis and treatment of pigmented skin lesions can likely improve patient outcomes., (Published by Elsevier Inc.)

Background: Telemedicine is improving access to subspecialty care within the Veterans Health Administration (VHA). Mohs micrographic surgery (MMS) is a surgical modality used to treat nonmelanoma skin cancers., Objective: This study evaluates the use of teledermatology for preoperative consultation for MMS., Methods and Materials: A retrospective analysis of interfacility MMS referrals to the Bronx Veterans Affairs Medical Center (VAMC) was conducted. The consult failure rates (CFRs), treatment follow-through rates, time to treatment, and travel savings for "face-to-face" preoperative consults were compared with store-and-forward "teledermatology" preoperative consults., Results: Although both "teledermatology" and "face-to-face" preoperative consults resulted in an equivalent percentage of treated lesions, teledermatology had a significantly decreased CFR. In addition, teledermatology decreased the time to treatment by 2 weeks, increased the percentage of lesions treated within 60 days, and resulted in average travel savings of 162.7 minutes, 144.5 miles, and $60.00 per person., Conclusion: This study demonstrates that teleconsultation is effective for preoperative consults for MMS within the VHA system. Teledermatology improved access measures such as time to treatment and travel burden. This program may serve as a model not only for other VAMCs that accept interfacility MMS consults, but also for VAMCs that provide other types of access-limited subspecialty care.

Importance: Patients are satisfied when surgical outcomes meet their expectations. Dissatisfaction with surgical scars is one of the most common reasons that patients sue surgeons who perform Mohs micrographic surgery (MMS)., Objective: To measure the accuracy of patient and physician estimations of scar length prior to skin cancer removal with MMS., Design, Setting, and Participants: This cross-sectional study was conducted between December 1, 2017, and February 28, 2018, at the MMS clinic of a single tertiary referral center health system. A total of 101 adults presenting for MMS for treatment of facial skin cancers volunteered for this study, and 86 surgeons who performed the MMS procedure participated., Main Outcomes and Measures: Patients and physicians independently drew the anticipated scar length on the patients' skin prior to surgery. Preoperative estimates by patients and surgeons were compared with actual postoperative scar length., Results: Of the 101 patients who participated, 57 patients (56.4%) were men and 57 patients (56.4%) were aged 65 years or older. Eighty-four patients (83.2%) underestimated scar length, whereas 67 of the 86 surgeons (77.9%) correctly estimated the scar length (P < .001). The actual postoperative scar length was 2.2 (interquartile range, 1.5-3.6) times larger than the patients' preoperative estimate but only 1.1 (interquartile range, 1.0-1.2) times larger than the surgeons' preoperative estimate (P < .001). Preoperative consultation with the surgeon, a personal history of MMS, or patient-directed research about MMS were not associated with improvement of patients' estimations of scar length., Conclusions and Relevance: This study's findings suggest that patients with facial skin cancers have unrealistic expectations regarding scars that measure, on average, less than half the length of the actual postoperative scars. Surgeons appear to accurately estimate the length of most surgical scars and have an opportunity to set realistic patient expectations about scar length before surgery.

Background: Sarcomas sometimes invade the skin and become exposed, producing malignant wounds characterized by bleeding, exudate, odor, and infection. Malignant cutaneous sarcomas are generally incurable and ultimately impair patients' quality of life. Mohs' chemosurgery is a previously published technique for chemical fixation of a cutaneous tumor and subsequent excision., Case Presentation: We present the case of a 44-year-old man with an undifferentiated pleomorphic sarcoma arising in the right chest wall and rupturing through the skin. The tumor manifested as a malignant wound with ulceration, bleeding, exudate, and a strong odor. Treatment with systemic chemotherapy and Mohs' chemosurgery was initiated. After repeated courses, the tumor demonstrated significant shrinkage. We were then able to perform wide resection and reconstruction with a rectus abdominis musculocutaneous flap. Pathologic examination of the resected specimen confirmed negative margins., Conclusions: Mohs' chemosurgery with concurrent systemic chemotherapy is an effective and reliable treatment option for achieving pre-operative local control of sarcomas that rupture through the skin.

Background: The lips provide key functional and aesthetic features of the face. From social interactions and speech to swallowing and oral competence, a functional dynamic structure is required. This interaction with surrounding landmarks presents a challenge for reconstruction. There are a myriad of ways reported to reconstruct these defects; however, as the authors' practice has evolved, a more refined approach was developed to optimize results and minimize the complexity of each patient's surgery., Methods: A retrospective review from 2004 to 2018 was performed of consecutive patients who underwent lip reconstruction following Mohs cancer resection performed by a single surgeon. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications. In addition, the evolution of treatment types over those 14 years was evaluated., Results: Six hundred fifteen patients underwent lip reconstruction. Defects most commonly involved the upper lateral lip, and 247 (40 percent) involved both the skin and vermillion. A significant majority of the patient's defects were repaired using either linear closure or V-wedge excision and closure. A complication rate of 10.2 percent (n = 63) was found, ranging from oral incompetence to cancer recurrence. There was no significant difference in complication rates in patients older than 75 years, in smokers, or in patients who were on anticoagulation., Conclusions: The authors' techniques have evolved from more invasive advancement and rotation flaps to a more reliable linear closure method over the past 14 years. This study shows that lip reconstruction is safe in elderly patients, smokers, and patients who are on anticoagulation., Clinical Question/level of Evidence: Therapeutic, IV.

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.

There is currently no standardised reporting format for Mohs surgery with its operation reports mostly written in a narrative form making them prone to unintentional errors and omission of necessary data. Synoptic histology reporting is used to describe excised skin cancers such as melanomas and, more recently, squamous cell and basal cell carcinomas. Since Mohs surgery is utilised as the gold standard treatment for locally invasive squamous and basal cell carcinomas, we propose the use of our model of synoptic reporting to ensure the completeness and consistency of Mohs surgery operation reports., (© 2019 The Australasian College of Dermatologists.)

Background: Basal cell carcinoma (BCC) and Squamous cell carcinoma (SCC) are the most frequent skin cancers with a continuous increasing incidence and a cause of economic impact. Mohs micrographic surgery (MMS) is known as the gold-standard of treatment of non-melanoma skin cancer. Methods: The files of the patients treated with MMS were analysed during a 6 year period (2014-2019) and demographic information was extracted in addition to the information on tumor histology, localization of tumors, number of stages required for a complete removal of the tumors, and the evolution of the patients. We also analysed the information regarding the number and type of reconstructions performed. Results: Over the course of 6 years, 1,356 cutaneous tumors were treated in our clinic by means of MMS. BCC represented 80.5%, SCC 17.6%, and other tumors such as melanoma in situ, DFSP, Extramammary Paget's Disease - being 1.9% of the number of other treated tumors. During the period under review, only 4 cases of post-Mohs Micrographic Surgery recurrence have been recorded, with a cure rate of over 99.7%. Conclusions: Mohs micrographic surgery is an efficient treatment method in removing cutaneous carcinoma as well as tumors with special indications with a low recurrence rate therefore reducing the need of successive surgical interventions., (Celsius.)

A 60-year-old healthy man presented with several enlarging, tender, spontaneously bleeding, and episodically pruritic nodules on his ear. Five agminated pink-red papulonodules of the superior postauricular sulcus were noted on examination. Pathological examination revealed a lobular dermal vascular proliferation with plump endothelial cells protruding into the lumen in a hobnail pattern, along with a dense perivascular inflammatory infiltrate composed of plasma cells, lymphocytes, and numerous eosinophils. The diagnosis of angiolymphoid hyperplasia with eosinophilia was confirmed. After discussing treatment modalities, the patient opted for Mohs micrographic surgery (MMS). Three stages of MMS were able to remove all large vessel involvement and clear the peripheral margins, but the tumor had a complex branching pattern of growth in the deep bed of the wound with numerous tiny foci remaining. Owing to risk of disfigurement, no further excision was undertaken. The area was reconstructed with a temporalis fascia flap and a full-thickness skin graft. Despite remaining microscopic disease, the patient remained without recurrence or symptoms at one year of follow up.

Background: Mohs surgery was developed for the treatment of advanced skin cancers. Advanced centrofacial tumors are among the most challenging lesions., Objective: The objective of the study was to review the most complex midface cases from our practice and to delineate how to plan the approach to these lesions, how to remove them in a step-by-step fashion, and how the patients were managed in a multidisciplinary manner when indicated., Methods: We reviewed 15 years of the most complex tumors to present to our practice for which Mohs micrographic surgery was performed. Follow-up for patients ranged from 3 to 13 years and is ongoing., Results: Twenty cases were identified in which tumors of the central face extended to bone and created extensive operative wounds. Eleven lesions were recurrent at presentation, and 9 had perineural disease. These cases are reviewed sequentially and demonstrate the challenges, successes, and pitfalls of Mohs micrographic surgery in the treatment of the most difficult tumors. Two patients died from disease., Conclusion: Mohs surgery is an excellent technique for the removal of extensive midfacial lesions and allows for the surgical removal of lesions that might otherwise be considered inoperable. Approach to these lesions requires careful planning, meticulous surgical technique, excellence in histology, and an experienced reconstructive surgeon. Such tumors often require a multidisciplinary approach, imaging, and adjuvant therapy. All such cases require diligent follow-up. Although many such lesions will be cured, regional recurrence and metastasis may result, even when clear margins are achieved.

Background: Skin cancers of the periorbital area present unique challenges to Mohs surgeons., Objective: The need for precise and high-quality Mohs micrographic surgery (MMS) is paramount because of the complex anatomy, vital structures, and potential threat to vision., Methods: A thorough comprehension of anatomy is essential to help predict tumor behavior and ensure successful outcomes for patients., Results: Tumors occurring at the medial and lateral canthi are of greatest concern for deeper orbital penetration., Conclusion: In this study, we present our experience with MMS of periorbital tumors, including clinical pearls and techniques to aid the Mohs surgeon.

Background: Mohs micrographic surgery (MMS) is the most reliable tissue-sparing technique in the management of cutaneous malignancies. Although the concept is simple, there is considerable variability in the mapping and processing techniques used by Mohs surgeons and histotechnicians., Objective: This review article aims to examine the frozen-section tissue processing techniques. Existing variations will be discussed and pearls offered to optimize the frozen processing technique., Methods: A PubMed search was performed for publications on methods of tissue processing in MMS., Results: Our review highlights variations in debulking, embedding, processing adipose tissue, cartilage, and wedge resections. We offer pearls on how to avoid false-positive and false-negative margins and discuss advances in immunohistochemistry., Conclusion: Our article provides a how-to format on the different stages of tissue processing with pearls and techniques to optimize practice and improve accuracy.

Background: Mohs micrographic surgery (MMS) is often the treatment of choice for skin cancer removal as it maximizes normal tissue sparing and can be paired with a reconstructive approach that optimizes function and cosmesis. Many tumors on the eyelid, nose, ear, and genitals are particularly well suited for MMS but can be challenging for the dermatologic surgeon., Objective: To review the complex anatomy, as well as the authors' approach to executing and interpreting Mohs layers, at each of these anatomical sites., Methods: A review of the literature on MMS of the eyelid, nose, ear, and genitals was performed using the PubMed database and relevant search terms., Conclusion: These sites present potential pitfalls for tumor resection and reconstruction, but with the proper technique, the dermatologic surgeon can minimize tumor recurrence and MMS complications. Warning signs for potentially difficult tumor resection can signify when an interdisciplinary approach is warranted.

Background: The scalp presents unique surgical challenges, and specialized techniques are sometimes required to achieve optimal results. Tumors arising on the scalp may also be at increased risk of complications such as in-transit metastasis and perineural invasion., Objective: To review challenges to Mohs micrographic surgery on the scalp and techniques for successful tumor extirpation and reconstruction., Methods and Materials: This article reviews our experience with tumors of the scalp including techniques that we have found helpful both for tumor removal and for reconstruction., Conclusion: Familiarity with the anatomy of the scalp as well as common challenges encountered during Mohs surgery may help improve outcomes and impart increase confidence to the practicing surgeon.

Background: Failure to perform Mohs micrographic surgery (MMS) meticulously on the nose and lips can lead to larger defects and tumor recurrence, which can have aesthetic and functional repercussions for patients., Objective: To review pre-, intra-, and postoperative techniques and pearls for performing MMS on the nose and lips to optimize outcomes., Materials and Methods: Technical nuances and pearls cultured from the authors' own practice, those acquired from mentors and colleagues, and information identified from the literature are discussed to provide a logical approach to performing effective MMS on the nose and lips., Results: When performing MMS on the nose and lips, sound preoperative preparation, precise surgical technique, and particular attention to reducing false-positives and false-negatives while harvesting Mohs layers enhances the fidelity of the MMS procedure, minimizing defect sizes and reducing tumor recurrence., Conclusion: Refining Mohs technique on the nose and lips allows more effective performance of tumor extirpation, improved microscopic evaluation, and more conservative reconstruction, leading to better patient outcomes.

Microcystic adnexal carcinoma (MAC) is a rare, malignant cutaneous neoplasm that often presents as an inconspicuous, benign appearing lesion. Patients most commonly are asymptomatic and present for improved cosmesis, however perineural invasion may result in local numbness, paresthesia or pruritus. Although distant metastasis is rare, MAC has an increased propensity for local invasion, often resulting in significant morbidity as late presentation and misdiagnosis are common. A high index of suspicion is imperative, and deep tissue biopsy with defining histologic characteristics is required for diagnosis. Mohs micrographic surgery is currently the standard of care, providing the highest possibility for long-term cure. We present a case report of a 43-year-old male Air Force U-2 pilot with a benign presentation and initial clinical misdiagnoses of MAC, who underwent Mohs micrographic surgery followed by cervicofacial flap reconstruction of a 5.5 × 3.5 cm defect. We also identify increased radiation exposure of U-2 pilots as a potential risk factor for the early development of MAC, emphasizing the importance of exploring patient risk factors while having a high index of suspicion to aid in early diagnosis., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Basal cell carcinomas are the commonest solid malignancy in humans and thought to grow faster in the periocular region. We measured growth rates between periocular and non-periocular nodular basal cell carcinomas in the head and neck region from high-resolution digital photos and operative notes. The non-periocular basal cell carcinomas (head and neck) showed a mean tumour volume doubling time of 129.8 ± 21.74 (n = 79) days, and the periocular basal cell carcinoma a mean of 177.5 ± 37.21 (n = 47) days. The unpaired t-test with Welch correction showed that this difference was not significant (p = 0.2719). The mean tumour volume doubling time was 147.59 ± 37.75 days for head and neck basal cell carcinomas overall. For the first time, tumour volume doubling times for nodular basal cell carcinomas in the periocular versus non-periocular regions for the head and neck area were analysed, with no significant differences demonstrated. Further, comparison of basal cell carcinoma growth rates with other common solid tumours confirmed that basal cell carcinomas are slow growing malignancies.

Background: Mohs micrographic surgery is a surgical technique for the treatment of nonmelanoma skin cancer. Surgery begins by removing the visible tumor before excision of the tissue specimens for evaluation of the tumor margins., Objectives: To present a new way to evaluate the material obtained from debulking, by horizontal histological analysis of the fragment., Methods: Descriptive retrospective cross-sectional study based on the medical records and histological lamellae of patients with primary basal cell carcinomas smaller than 1.5cm submitted to Mohs micrographic surgery and who had the visible tumor analyzed by horizontal histological sections., Results: The sample evaluated included 16 patients with lesions located on the face. Comparing the histopathological examinations of incisional biopsy in vertical sections and debulking in horizontal sections, there was agreement in seven cases. The histological analysis performed in horizontal sections allowed identification of the tumor site in 13 cases, and the relation between tumor and margin showed that in 11 cases, the lateral margin was compromised., Study Limitations: The technique was better-applied in lesions smaller than 2cm., Conclusion: Horizontal histological analysis of debulking has advantages for Mohs surgery, since it allows visualization of almost all tumor extension in the same view plane of the dermatoscopy, allowing better definition of the histological subtype, tumor site, and tumor/margin of lesions less than 1.5cm., (Copyright © 2019. Published by Elsevier España, S.L.U.)