Mohs micrographic surgery,☆☆,

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Abstract

Mohs micrographic surgery (MMS) is a specialized type of minimal marginal surgery that offers cure rates superior to other options in the treatment of contiguous skin cancers in selected settings. Developed by Dr. Frederic E. Mohs, the technique originally required in situ tissue fixation before excision. Most Mohs micrographic surgeons now use the fresh tissue technique exclusively. Horizontal frozen histologic sections of the excised tumor permit more complete microscopic examination of the surgical margin than traditional methods. Residual tumor is graphically mapped and malignant extensions are pursued with staged excisions until the tumor is removed. Maximum sparing of tumor-free adjacent tissue is achieved with histologic mapping of the tumor boundaries, thus optimizing subsequent wound reconstruction. The history, techniques, indications, cure rates, and current controversies of MMS are reviewed. (J Am Acad Dermatol 1998;39:79-97.)

Section snippets

HISTORY

The concept of sequential tumor removal was originated by Frederic E. Mohs while working as a cancer research assistant during medical school in the early 1930s.8, 9 While testing the irritant effect of an injected 20% zinc chloride solution upon transplantable cancers, Mohs noted that the treated tissue maintained its normal microscopic architecture as if it had been immersed in a fixative solution. This observation initiated the idea of excising cancer under microscopic control. The

TECHNIQUE

Today, the fixed-tissue technique is infrequently performed. In a recent survey, 72% of Mohs micrographic surgeons used the fresh-tissue technique exclusively. The remainder used the fixed-tissue technique in the treatment of less than 5% of their patients.15 Some physicians elect to use the fixed-tissue technique in certain circumstances. For example, the blood-free field achieved with the fixed-tissue technique may offer an advantage for the treatment of vascular tumors and tumors arising in

INDICATIONS

Many variables are considered in the evaluation of a patient for MMS. MMS is indicated for locally aggressive tumors that are difficult to eradicate by routine methods. Clinical morphology, histology, tumor size, level of invasion, anatomic location, patient immunity, and recurrence after previous treatment are criteria to be considered (Table I).1, 37, 38, 39, 40, 41

. Selection criteria for Mohs micrographic surgery

Recurrent tumors
Tumors located in anatomic areas associated with a high risk of

LIMITATIONS

Although MMS has the obvious advantages of high cure rates and tissue conservation, there are some relative disadvantages.19 MMS is labor intensive and requires the expertise of a qualified surgeon and a trained nursing staff. An experienced histology technician must be available to produce on site horizontal frozen sections. One cost of greater accuracy is time, and the patient must be cooperative about waiting between stages.

Achieving complete tissue samples for microscopic examination can

RECONSTRUCTION

Several wound repair options are considered by the Mohs micrographic surgeon after tumor removal. Of primary concern is the possibility of burying residual tumor beneath complicated repairs. Undermining and rearrangement of the skin architecture may allow various and extensive paths of minimal resistance for recurrent tumor growth. With overlying full-thickness skin, the recurrent tumor may not be visible until it has grown large enough to invade through the overlying skin. If there is special

THE MULTIDISCIPLINARY APPROACH TO SKIN CANCER

Once the tumor has been excised with tumor-free margins, a variable-sized defect remains. Usually, the Mohs micrographic surgeon performs the repair as discussed above. However, when the defect is particularly large, complex, or involves vital structures, it becomes advantageous to collaborate with a specialized reconstructive surgeon, such as a plastic surgeon, otorhinolaryngologist, or ophthalmologist.1, 18, 42, 48, 71, 155 The added benefit of such specialization is that the Mohs

TRAINING IN MOHS MICROGRAPHIC SURGERY

Because tumor size cannot always be predicted before excision, the Mohs micrographic surgeon should be trained to manage all aspects of small tumor excisions as well as excisions of large, deeply invasive tumors that involve vital structures. These aspects include anesthesia, surgical technique, anatomy, dermatopathology, and wound reconstruction, in addition to a detailed understanding about all technical aspects of MMS. In the past, this type of special detailed knowledge and surgical

DISCUSSION

MMS is an effective technique for the removal of contiguous malignancies. By using precise surgical margin control, high cure rates are achieved for difficult malignant skin tumors, while providing maximum tissue preservation. For skin cancers that are located in vital anatomic areas or have a significant likelihood of recurrence with conventional treatment methods, MMS is often preferred by both physician and patient.

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      Standard excision requires wide and often mutilating margins to achieve complete excision.2-4 Alternatively, Mohs micrographic surgery, regarded as the gold standard for high-risk BCC, offers a more conservative approach, but recurrence rate increases significantly with increasing tumor diameter.5,6 Moreover, Mohs micrographic surgery is extremely time consuming for large aggressive specimens.2,6

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    Used with permission from Lippincott-Raven Publishers, excerpts, figures, and tables are from Shriner DL, Wagner RF, Goldberg DJ: Mohs micrographic surgery. Clinical Dermatology, Unit 37-2, 1995.

    ☆☆

    Reprint requests: Dr. Richard F. Wagner, UTMB Dermatology, Galveston, TX 77555-0783.

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