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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: Mohs micrographic surgery, excisional surgery, and electrodessication and curettage (ED&C) are common dermatologic procedures that often use electrodessication through hyfrecators to achieve hemostasis. According to in vitro studies, electrodessication is considered safe in patients with implanted cardiac devices. To the authors' knowledge, there are no in vivo data to support this claim., Objective: In this study, the authors aim to describe the outcomes of hyfrecation during dermatologic procedures in patients with pacemakers and implantable cardiac devices., Methods: Retrospective chart review was completed from March 2014 to April 2018 at a single center. Forty-five patients met criteria of having a cardiac device and having undergone an electrosurgery procedure using the Conmed 2000 Hyfrecator (Utica, NY). Adverse perioperative and postoperative outcomes, as well as device malfunction, were evaluated., Results: No adverse perioperative effects were reported. Device reports were examined for inappropriate firing of the defibrillator, loss of capture, temporary inhibition of pacing, battery drainage, pacing at an elevated or erratic rate, failure to deliver antitachycardia, reversion to asynchronous pacing, induction of arrhythmias, or tissue damage at lead tissue, but no such issues were found., Conclusion: The lack of complications associated with cardiac devices with hyfrecation is reassuring. However, prospective and larger retrospective studies are warranted.

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.

Background: Surgical fire is a rare event, but one with potentially devastating patient outcomes., Objective: This study was conducted to investigate the incidence, risk factors, and outcome of surgical fires experienced by members of the American College of Mohs Surgeons (ACMS)., Methods: An internet survey was developed and sent to ACMS members. Data collected included total years of experience, total number of cases, typical management of supplemental oxygen, and surgical fires experienced., Results: Eighty participants contributed data on 886,200 cases of MMS. Nine surgeons (11%) reported at least 1 surgical fire, yielding an estimated incidence of 1 fire per 88,620 cases (0.001%). The most common site of involvement was the scalp (67%). Common ignition sources included monopolar electrosurgical devices (78%) and battery-powered thermal cautery (22%). Fuel sources included towels or drapes, gauze, isopropyl alcohol, aluminum chloride, hairspray, and diethyl ether. Supplemental oxygen was not involved in any of the cases. Five patients suffered singed hair while 4 patients did not suffer any injuries. None suffered any permanent functional or aesthetic deformities., Conclusion: The overall risk of surgical fire in MMS is minimal. However, safety measures and greater awareness of fire risks are necessary to prevent patient harm.

Background: Effective treatment by Mohs micrographic surgery requires preparation of high-quality slides., Objective: To examine a novel tissue alignment device designed to address variability in tissue processing because of excessive sample trimming., Materials and Methods: A device was designed to account for angular errors and unparalleled tissue embedding. A retrospective chart review was performed both with and without the use of the device over the course of a 4-year period (2012-2015)., Results: Between January 1, 2012, and June 10, 2014, before device implementation, mean number of stages per case was 1.65 (n = 3,680) and mean number of surgeries per day was 6.34 (n = 640). Between June 11, 2014, and October 02, 2015, with device implemented, the average number of stages per case between decreased to 1.58 (n = 2,562) and the number of daily surgeries increased to 7.05 (n = 358). This represents a significant decrease in number of stages per case by 0.07 stages (95% CI: -0.01 to -0.13, p = .02), as well as an increase in the number of cases per day by 0.71 cases (95% CI: 0.12-1.3, p < .01)., Conclusion: Slide preparation using the novel alignment device may result in less tissue waste and more cases being performed daily.

Confocal mosaicking microscopy (CMM) enables rapid imaging of large areas of fresh tissue ex vivo without the processing that is necessary for conventional histology. When performed in fluorescence mode using acridine orange (nuclear specific dye), it enhances nuclei-to-dermis contrast that enables detection of all types of basal cell carcinomas (BCCs), including micronodular and thin strands of infiltrative types. So far, this technique has been mostly validated in research settings for the detection of residual BCC tumor margins with high sensitivity of 89% to 96% and specificity of 99% to 89%. Recently, CMM has advanced to implementation and testing in clinical settings by “early adopter” Mohs surgeons, as an adjunct to frozen section during Mohs surgery. We summarize the development of CMM guided imaging of ex vivo skin tissues from bench to bedside. We also present its current state of application in routine clinical workflow not only for the assessment of residual BCC margins in the Mohs surgical setting but also for some melanocytic lesions and other skin conditions in clinical dermatology settings. Last, we also discuss the potential limitations of this technology as well as future developments. As this technology advances further, it may serve as an adjunct to standard histology and enable rapid surgical pathology of skin cancers at the bedside.

We report several scenarios of compromise in patient safety owing to the re-use of mis-assigned patient's surgical instruments in Mohs micrographic surgery.We discuss the breaks in universal protocols that others may experience in their practices and describe corrective measures that our institutions employed to avoid such future events.There is a lack of publication in the literature on the topic of mis-assigned instrument use in Mohs surgery. We believe that the  practice of re-using instruments is cost-effective and therefore common. Based on our humbling experience, this publication may initiate important discussion among dermatologist regarding safety protocols at their respective institutions.

Purpose: To validate the innovative Dry Ice method, comparing it with two standard methods currently used for tissue processing in Mohs surgery, the Heat Sink method and the Miami Special., Methods: Forty eight samples of pigs kin with the standard beveled Mohs technique were used, and randomly allocated into six groups. Each group was processed with one of the 3 methods and evaluated for: The freezing time, the depth required to cut into the block to obtain a complete section, and the quality of histological slides analyzed with a image software. The statistical analysis was performed with the software SAS(r) System. The inferential analysis was made by one-way ANOVA., Results: The Miami Special showed a processing time significantly shorter than Dry Ice method and Heat Sink method. There was no significant difference in the depth required to cut into the blocks, and area of surgical margins visualized., Conclusion: The Dry Ice method was as efficient as the other two methods currently used in Mohs surgery, considering the individual advantages and disadvantages of each method.

Mohs micrographic surgery (MMS) is a treatment method aiming at thorough, personalized eradication of skin cancers by mean of staged excision of tissues surrounding the tumor with complete (100%) histopathological examination of their margins. In many MMS laboratories, the excised tissue is divided, shaped, frozen in a cryostat with a heat extractor and positioned manually (with the block on the object disc) in an articulated cryostat chuck during cutting. However, these activities may be difficult, time-consuming and associated with the risk of imprecise tissue sectioning. Development of a laboratory device allowing for processing of large tissue specimens, with the function of mechanical, mathematically steered positioning of the tissue block surface directly to the microtome knife cutting place, eliminating the need for manual adjustment. The prototype device was designed and manufactured. Its functioning was tested on 513 histological slides produced during 212 operations of skin cancers using MMS. The depth of the first complete sections and the diameter of sections were measured. Complete sections were obtained at an average depth of 81.60 m (min. 20 m, max. 180 m, SD = 29.15), whereas the average diameter of sections was 18.11 mm (min. 4 mm, max. 42 mm, SD = 9.10). The histological processing of large specimens with mathematically based positioning of the tissue surface in relation to the cryotome knife cutting plane is precise, fast and easy. The device can be useful in those MMS centers which continue to employ manual setting of the cryostat chuck or share the cryostat with other users, which prevents fixing the chuck position (including large hospital settings). It may also be helpful in centers using a cryostat with a fixed chuck, for the correction of minimal inaccuracies of its preset position.

A useful application of the flexible razor blade in Mohs micrographic surgery that can save time and result in a well-presented specimen is described., (© 2015 The Australasian College of Dermatologists.)

Background: Mohs micrographic surgery (MMS) has a low rate of surgical site infections (SSI). To date, there are variations in the measures surgeons take to prevent SSI, although these may be costly without benefit to patients., Objective: The purpose of the study was to evaluate the rate of SSI in MMS performed with a clean technique using a single set of instruments for both tumor extirpation and reconstruction., Materials and Methods: The author prospectively evaluated 338 patients undergoing MMS using a single set of instruments for SSI., Results: There were 7 SSI among 332 patients, with an overall infection rate of 2.1% (7/332). Graft closures had an SSI rate of 3.1% (2/64) and flap closures had an SSI rate of 1.9% (5/268)., Conclusion: Using a single set of sterile surgical instruments for both the tumor extirpation and repair stages of MMS leads to cost savings without harming patients and maintains SSI rates within an acceptable range.

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.

Background: 3D histology-guided surgery provides high cure rates and tissue-sparing for the treatment of basal cell carcinomas (BCCs). The cockade technique is a closed wound variant of 3D histology-guided surgery, which has previously been designed to provide low postoperative complication rates and good feasibility in the office-setting., Objectives: We examined the postoperative complication rates and feasibility of the cockade technique with a new double-bladed scalpel in the routine office setting., Patients and Methods: 145 patients with 213 BCCs of the head and neck areas were treated between July 2010 and August 2012. All patients underwent 3D histology-guided surgery with the cockade technique. The rates of postoperative surgical site infection (SSI) and postoperative bleeding were recorded. Also the feasibility of the cockade technique was examined., Results: 0.9 % of BCCs sites developed SSI, while no postoperative bleeding problems or hematomas were recorded. 94 % of the BCCs were completely excised in two surgical stages. The cockade technique allowed flexible scheduling of operation room use. In addition, the small margin strips taken by the new double-bladed scalpel could be evaluated microscopically without gaps., Conclusions: The cockade technique is a practical method with low complication rates for the treatment of BCCs and can be easily integrated into outpatient care., (© The Author | Journal compilation © Blackwell Verlag GmbH, Berlin.)

Confocal mosaicing microscopy is a developing technology platform for imaging tumor margins directly in freshly excised tissue, without the processing required for conventional pathology. Previously, mosaicing on 12-×-12  mm² of excised skin tissue from Mohs surgery and detection of basal cell carcinoma margins was demonstrated in 9 min. Last year, we reported the feasibility of a faster approach called "strip mosaicing," which was demonstrated on a 10-×-10  mm² of tissue in 3 min. Here we describe further advances in instrumentation, software, and speed. A mechanism was also developed to flatten tissue in order to enable consistent and repeatable acquisition of images over large areas. We demonstrate mosaicing on 10-×-10  mm² of skin tissue with 1-μm lateral resolution in 90 s. A 2.5-×-3.5  cm² piece of breast tissue was scanned with 0.8-μm lateral resolution in 13 min. Rapid mosaicing of confocal images on large areas of fresh tissue potentially offers a means to perform pathology at the bedside. Imaging of tumor margins with strip mosaicing confocal microscopy may serve as an adjunct to conventional (frozen or fixed) pathology for guiding surgery.

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.

Imaging large areas of tissue rapidly and with high resolution may enable rapid pathology at the bedside. The limited field of view of high-resolution microscopes requires the merging of multiple images that are taken sequentially to cover a large area. This merging or mosaicing of images requires long acquisition and processing times, and produces artifacts. To reduce both time and artifacts, we developed a mosaicing method on a confocal microscope that images morphology in large areas of excised tissue with sub-cellular detail. By acquiring image strips with aspect ratios of 10:1 and higher (instead of the standard ~1:1) and "stitching" them in software, our method images 10 × 10 mm(2) area of tissue in about 3 min. This method, which we call "strip mosaicing," is currently three times as fast as our previous method.

Reconstruction of the scalp after Mohs surgery can pose dilemmas for the dermatologic surgeon, especially for extensive tumors. The authors present a unique technique for removing large in-situ epidermal tumors of the scalp during Mohs surgery in four patients. Although invasive tumor was removed with a standard No. 15 scalpel, the extensive epidermal component of the tumor was removed through the mid-dermis using the flexible scalpel. This technique allowed the superficial defect to heal by second intention. The results showed minimal scarring and hair regrowth in what could have been large defects requiring complex reconstruction.

Background: Malignant proliferating trichilemmal tumor (MPTT) is a rare neoplasm originating in the outer sheath of a hair follicle that often presents as a slowly enlarging, painful, subcutaneous scalp nodule. The authors describe a case of malignant proliferating trichilemmal tumor (MPTT) in an elderly 65-year-old Asian male who presented with a 5.5 x 5.0 cm mass on the posterior scalp., Methods: The authors present a unique dual approach to treatment of MPTT in both the excision and wound revision phases. First, Mohs micrographic surgery is utilized for more discrete removal of malignant tissue, as opposed to wide excision. Then, a novel device called DermaClose RC is used in wound revision, a device that has proven to be more effective in promoting wound closure than traditional suturing., Results: Mohs micrographic surgery was used to excise the tumor in three stages. The resulting irregular wound measured 6.3 x 5.6 cm, and was repaired with the device. Following the application of the device, the wound reduced in size to 1.5-1.0 cm. Postoperatively, the patient had no evidence of recurrent disease at seven months., Conclusion: Use of the DermaClose RC tissue expander following a Mohs surgical procedure provides an effective functional and cosmetic alternative to a skin graft which creates a donor site wound and creates a more complicated, time consuming procedure. The dual approach discussed here-of Mohs micrographic surgery performed in tandem with wound revision via the tissue expanding device is one that may yield promising benefits but warrants further evaluation.

Objective: Mohs surgery is a frozen section-guided surgical excision that is the treatment of choice for aggressive cutaneous malignancy. But it is labour intensive, particularly because numerous levels are needed on each specimen to obtain a complete histologic section. Three different techniques to Mohs surgery are compared. Our new approach with moulds and glass discs is explained and discussed., Design: Review of the literature and comparative study using skin specimens of fresh cadavers., Setting: Regional care centre., Method: First, we evaluate, for each of the three different techniques, the number of 10 micron-thick frozen sections required to obtain a macroscopically complete cross section of the specimen. Second, we examine microscopically the quality of these first complete sections. Finally, once we have obtained a macroscopically complete cross section, we evaluate the number of deeper levels required to obtain an adequate microscopic section., Results: In the first experiment, with the modern method, 90.1 sections were needed to obtain a full macroscopic section, 36.8 sections with the heat extractor method, and 10.6 sections with the new mould. The quality of the histologic glass slides was superior with the new mould. The number of deeper levels required to obtain an adequate microscopic section was 5.9 for the modern method, 4.4 for the heat extractor method, and 2.3 for the new approach (new mould)., Conclusion: Our new approach with moulds and glass discs is simple and allows us to flatten the specimen (to obtain a complete tissue section) more reliably and efficiently compared with both the modern and the heat extractor methods. The new approach allows us to obtain these results in less time and with fewer histologic glass slides. Some other aspects are discussed.

Background: Ex vivo confocal scanning laser microscopy offers rapid optical reflectance imaging of excised tissue without conventional frozen histopathology that can potentially expedite Mohs surgery., Objective: The objective was to determine the feasibility of using ex vivo confocal scanning laser microscopy during Mohs surgery for detecting residual basal cell carcinoma and squamous cell carcinoma., Methods: One-hundred fifteen Stage I Mohs surgery excisions (92 basal cell carcinoma, 23 squamous cell carcinoma) were imaged with acetowhitening and confocal scanning laser microscopy and compared to conventional Mohs frozen histologic sections for normal and tumor features., Results: Large aggregates of residual tumor such as nodular basal cell carcinoma were easily detected by ex vivo confocal scanning laser microscopy, whereas smaller tumor foci were not consistently identified. Confocal morphology of tumor subtypes is described., Conclusion: Ex vivo confocal scanning laser microscopy can potentially expedite Mohs surgery in rapidly detecting large nodular basal cell carcinomas without conventional frozen histopathology. Further improvements in instrumentation and image quality are necessary to allow broader application and acceptance of this novel technology in Mohs surgery.

Background: Imiquimod is an immune response modifier that up-regulates cytokines and has been shown in clinical studies to reduce or clear basal cell carcinoma tumors when applied topically., Objective: The objectives were to evaluate the efficacy of 5% imiquimod cream in treating basal cell carcinoma preceding excision by Mohs micrographic surgery and to determine if reflectance-mode confocal microscopy is useful to establish the need for surgical intervention after imiquimod treatment., Methods: Subjects applied study cream to one biopsy-confirmed basal cell carcinoma tumor 5 x/week for 2, 4, or 6 weeks in this vehicle-controlled, double-blind study. Confocal microscopy was used for the 6-week treatment group to examine the target tumor area at each interval visit and immediately before Mohs micrographic surgery. After the Mohs micrographic surgery excision, the tissue was evaluated histologically, and the excision area was measured. Confocal microscopy readings were correlated to the histologic diagnosis., Results: Tumors cleared or the target tumor area was reduced in subjects in the 4- and 6-week dosing regimens. Confocal microscopy assessments correlated well with the histologic diagnosis., Conclusion: Imiquimod improved excision results relative to vehicle when used for treating basal cell carcinoma before Mohs micrographic surgery. Confocal microscopy assessments correlated well with tumor response to therapy, suggesting that confocal microscopy may help determine the need for surgery.

Mohs micrographic surgery has evolved over the last 60 years from fixed-tissue chemosurgery with secondary intention healing to fresh-tissue surgical excision utilizing advanced histotechnology and reconstructive techniques. This evolution has occurred while preserving the fundamental characteristics of Mohs surgery: microscopically controlled tumor excision by one surgeon acting as pathologists to ensure complete tumor extirpation while maximally conserving tissue. Refinements, modifications, and clinical pearls will be outlined that uphold these tenets and enhance the quality of patient care.

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.

Background: Mohs micrographic surgery is a highly successful technique for removing skin cancers while conserving normal tissue. However, conservation of the deep margins can often be difficult to achieve when using a standard scalpel. An inability to conserve normal tissue at the deep margins can greatly impact the complexity of repair, duration of surgery, aesthetic result, and patient morbidity., Objective: To find an alternative method of obtaining Mohs specimens that offers greater control of the depth of incision when compared to the standard scalpel., Methods: We utilized a flexible scalpel to obtain Mohs levels on patients with superficial cutaneous malignancies in anatomic locations where careful conservation of the deep margins would allow for less extensive repair., Results: For those patients who had tumor-free margins after one level of Mohs surgery, the shallower defects achieved with the flexible scalpel allowed for excellent cosmetic outcomes and decreased patient operative time and morbidity., Conclusion: The flexible scalpel is both effective and efficient in obtaining thin Mohs specimens when conservation of the deep margin is of utmost importance.

Objective: Simple yet effective modifications to Mohs surgery and processing may enhance procedural efficiency, ensure proper tissue orientation and tracking, while greatly reducing "recuts." Using the methods described, Mohs specimens no longer need to be incised or excised with any bevel, thus conserving tissue and facilitating closure., Methods: A streamlined Mohs surgical tray is convertible to a closure tray within seconds. The excised tissue specimen is oriented on a sterile paper square on a reusable sterilized aluminum palette where partial thickness circumferential and radial scalpel cross-hatching allows epidermal edges complete freedom to later adhere to a flattening glass. The sterile paper can be labeled with patient name, stage number, and chuck number; then the specimen is inked. Rapid chuck freezing in a specially positioned liquid nitrogen immersion is followed by OCT (embedding compound) application. Uniquely numbered and modified cryostat chucks eliminate the possibility of OCT-chuck disunion. Rapid liquid nitrogen immersion of a glass surface allows the inked, cross-hatched specimen's epidermal edges and base to lay perfectly flat once forced against the supercooled glass surface using a special polymer glove. Inversion of the specimen-containing glass onto a frozen and gel state OCT interface of the chuck completes the embedding., Results/conclusion: These reproducible approaches to Mohs surgery described herein utilize multiple modifications that enhance the speed, efficiency, and reproducibility of Mohs specimen embedding, specimen preparation, while maintaining accuracy of interpretation.

Background: The double-bladed scalpel previously has not been cited in the published literature for use in Mohs micrographic surgery., Objective: To allow for maximum tissue conservation and greatest possible intraoperative efficiency for peripheral margin control of a massive tumor., Methods: We describe the use of the double-bladed scalpel during Mohs surgery for peripheral margin control of a large dermatofibrosarcoma protuberans (DFSP)., Results and Conclusion: While not necessary for the majority of routine Mohs cases, utilization of the double-bladed scalpel may be timesaving, especially when used for peripheral margin control of a massive tumor.