Mohs Surgery for SEER Registry-Captured Melanoma In Situ and Rare Cutaneous Tumors: Comparing National Utilization Patterns Before and After Implementation of the Affordable Care Act (2010) and Appropriate Use Criteria (2012).

BACKGROUND: The Affordable Care Act (ACA) and the appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) had the potential to increase utilization rates of MMS for indicated skin cancers, but it is unknown whether this has occurred. OBJECTIVE: To determine whether rates of MMS utilization for head and neck melanoma in situ (MIS) and rare cutaneous tumors (RCTs) increased after the implementation of the ACA and AUC publication. MATERIALS AND METHODS: Retrospective review using data from the SEER database. Melanoma in situ and RCT tumor cases from before and after the ACA and AUC publication were compared. RESULTS: Twenty-four thousand six hundred seventy-eight cases were analyzed. Mohs micrographic surgery utilization for MIS decreased from 13.9% before the ACA to 12.3% after the ACA (odds ratio 0.87; p = .012). There was no significant change in MMS utilization for MIS after publication of the AUC. There was also no significant change in MMS utilization for treatment of RCT after the ACA or AUC publication. Stratification of patients into age groups younger or older than 65 years did not change utilization rates. CONCLUSION: Rates of MMS for treatment of MIS and RCT have not increased since the advent of the ACA or AUC. This finding highlights the need for continued efforts to improve access to MMS and to increase education of its utility in treating skin cancer.

Teledermatology as a Tool for Preoperative Consultation Before Mohs Micrographic Surgery Within the Veterans Health Administration.

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.

Mohs Micrographic Surgery at the Skin and Cancer Foundation Australia, 20 Years Later (1997-2017).

BACKGROUND: The availability of Mohs micrographic surgery (MMS) in Australia has increased dramatically since its inception in the 1980s. OBJECTIVE: This study aimed to describe the evolution of MMS practices at the Skin and Cancer Foundation Australia (SCFA) over the past 20 years (1997-2017). METHODS: Retrospective analysis of Mohs surgery cases at SCFA in 2017, 2007, and 1997, comparing data on sex, age, tumor type and site, initial tumor and final defect size, number of surgical stages and sections, and closure management. The present study is limited by being a retrospective analysis from a single institution. RESULTS: There was a 415% increase in the number of Mohs surgery cases from 1997 to 2017, and a significant increase in Mohs surgery-treated squamous cell carcinoma. The preoperative tumor and final defect size have decreased. More side-to-side closures and fewer grafts are being performed over time. LIMITATIONS: Retrospective analysis from a single institution. CONCLUSION: Over the last 20 years, MMS has remained appropriate in its application and is being increasingly used for treatment of squamous cell carcinoma suggesting improved access.

Mohs Micrographic Surgery: Past, Present, and Future.

BACKGROUND: Mohs micrographic surgery (MMS) is a frequently used technique that provides total margin visualization for treatment of skin neoplasms. OBJECTIVE: To provide a comprehensive review of MMS literature, focusing on its origins, evidence behind present-day uses of MMS, and future directions. METHODS: A literature search was conducted using PubMed to identify articles pertaining to MMS. RESULTS: The fresh frozen technique led to widespread use of MMS in the 1970s. One randomized controlled trial and several large prospective studies have demonstrated low recurrence rates for treatment of nonmelanoma skin cancer (NMSC). MMS, when compared with surgical excision, also achieved a statistically significant higher cure rate for treatment of recurrent NMSC. Studies have demonstrated low recurrence for the treatment of melanoma and melanoma in situ with MMS. MMS has also been shown to effectively treat several rare cutaneous neoplasms. The future of MMS is likely to include the adoption of noninvasive imaging, immunostaining, and digital technology. CONCLUSION: Mohs micrographic surgery is an effective treatment modality for numerous cutaneous neoplasms. It has achieved statistically significant superiority to surgical excision for the treatment of recurrent and high-risk NMSC. The future is likely to see increased use of noninvasive imaging, immunostaining, and digital technology.

Modernizing the Mohs Surgery Consultation: Instituting a Video Module for Improved Patient Education and Satisfaction.

BACKGROUND: Studies show that patients recall less than half of the information given by their physicians. Use of video in medicine increases patient comprehension and satisfaction and decreases anxiety. However, studies have not elaborated on video content. OBJECTIVE: To use principles of learning with multimedia to improve the Mohs surgery consultation. MATERIALS AND METHODS: The authors developed 2 informational videos on Mohs surgery: traditional versus narrative. The focus of the traditional video was purely didactic. The narrative video included patient testimonials, patient-physician interaction, and animations. New Mohs surgery patients viewed either the traditional (n = 40) or the narrative video (n = 40). Existing Mohs surgery patients (n = 40) viewed both videos. Both groups answered questionnaires about their satisfaction. RESULTS: For new Mohs surgery patients, no significant difference was found between the traditional and the narrative video groups because respondent satisfaction was high for both video formats. For existing Mohs surgery patients, all respondents (100%) reported that videos were helpful for understanding Mohs surgery; however, the majority would recommend the narrative over the traditional format (72.5% vs 27.5%, p = .01). CONCLUSION: Technology is useful for patient education because all patients preferred seeing a video to no video. Further research is needed to optimize effective multimedia use in patient education.

Reply to Letter: Effectiveness of Mohs and Close.

The following is a response to the Letter to the Editor by Konda, Francis, and Patel regarding the article "Mohs and Close" Technique (MCT) for selected cases to increase the efficiency of Mohs micrographic surgery.1,2 The letter raises questions about our utilization of MCT that require clarification.

Use of Google Trends to Examine Interest in Mohs Micrographic Surgery: 2004 to 2016.

BACKGROUND: Mohs micrographic surgery (MMS) is the gold standard for treatment of high-risk skin cancers. There has been an upward trend in the use of this procedure as demonstrated by data from Medicare and the National Ambulatory Medical Care Survey. OBJECTIVE: To assess interest in MMS among members of the general public as measured by number of online searches, and how that interest has changed over time. MATERIALS AND METHODS: Google Trends was used to plot interest in search terms including "Mohs surgery," "basal cell carcinoma," "squamous cell carcinoma," "melanoma," and "skin cancer" from January 1, 2004, to November 30, 2016. RESULTS: Search interest for the term "Mohs surgery" has steadily increased since 2004 and correlates closely with increased interest for "basal cell carcinoma" (r = 0.82) and "squamous cell carcinoma" (r = 0.85). Search interest in MMS did not correlate well with searches for melanoma (r = -0.15) or skin cancer (r = -0.29). CONCLUSION: Public interest in MMS has continued to steadily increase in the United States, which may be a reflection of the increasing volume of MMS that is performed.

Implementation of fluorescence confocal mosaicking microscopy by "early adopter" Mohs surgeons and dermatologists: recent progress.

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.

Trends in Mohs surgery from 1995 to 2010: an analysis of nationally representative data.

BACKGROUND: In Mohs surgery, the histologic verification of tumor removal results in a lower rate of cancer recurrence compared with simple excision. Factors associated with the increased use of Mohs surgery are not well characterized. OBJECTIVE: To investigate trends in the utilization of Mohs surgery. METHODS AND MATERIALS: The authors performed a retrospective analysis of the National Ambulatory Medical Care Survey for patient visits associated with Mohs surgery from 1995 to 2010. The authors assessed percentage of skin cancers managed with Mohs surgery, the most common locations of skin cancer managed with Mohs surgery, and patient demographics associated with Mohs surgery. RESULTS: Although there was an upward trend in the use of Mohs surgery (p = .004), a low percentage of skin cancers (average of 10.0%) were managed with this technique. When the surgical location was specified, Mohs surgery was most commonly used for the head and neck region. Demographic groups receiving Mohs surgery at higher rates included African Americans (44.2%) and patients aged 75 to 84 years (12.4%). CONCLUSION: There has been an upward trend in the use of Mohs surgery, particularly in the head and neck region where tissue preservation is essential.

Analysis of skin cancer treatment and costs in the United States Medicare population, 1996-2008.

BACKGROUND: There is a skin cancer epidemic in the United States. OBJECTIVE: To examine skin cancer treatment modality, location, and cost and physician specialty in the Medicare population from 1996 to 2008. METHODS: Centers for Medicare and Medicaid Services databases were used to examine skin cancer treatment procedures performed for Medicare beneficiaries. RESULTS: From 1996 to 2008, the total number of skin cancer treatment procedures [malignant excision, destruction, and Mohs micrographic surgery (MMS)] increased from 1,480,645 to 2,152,615 (53% increase). The numbers of skin cancers treated by excision and destruction increased modestly (20% and 39%, respectively), but the number of MMS procedures increased more rapidly (248% increase). Dermatologists treated an increasing percentage (75-82%) of skin cancers during these years, followed by plastic and general surgery. In 2008, more than 90% of all skin cancers were treated in the office, with the remainder being treated in facility-based settings. Allowable charges paid to physicians by Medicare Part B for skin cancer treatments increased 137% from 1996 to 2008, from $266,960,673 to $633,448,103. CONCLUSIONS: The number of skin cancer treatment procedures increased substantially from 1996 to 2008, as did overall costs to Medicare. Dermatologists treated the vast majority of skin cancers in the Medicare population, using a mix of treatment modalities, almost exclusively in the office setting.

Mohs micrographic surgery utilization in the Medicare population, 2009.

BACKGROUND: Mohs micrographic surgery (MMS) is the criterion standard treatment for high-risk skin cancers. Few data on current MMS Utilization are available. OBJECTIVE: To better understand current trends in MMS use in the Medicare population. METHODS AND MATERIALS: The 2009 Medicare Limited Data Set Standard Analytic File (LDSSAF), carrier claims, 5% sample and the Physician Supplier Procedure Master File (PSPMF) 100% summary were analyzed. RESULTS: In 2009, 558,447 Medicare MMS cases were performed, with an average of 1.75 stages per case. In the 5% claims sample, 0.3% and 1.3% of MMS cases were performed for melanoma and carcinoma in situ, respectively. Total annual volume predictions for 1,777 providers showed a left-shifted curve. 65.8% of LDSSAF cases had same-day MMS repairs: 48.7% of repairs were complex, 9.8% intermediate, 32.4% flaps, and 7.4% full-thickness skin grafts. CONCLUSIONS: The 5% LDSSAF is highly predictive of total claim volumes and is useful for modeling practice trends. There is wide variation in MMS provider annual case volume. These data reflect only Medicare Part B enrollees in 2009; 5% LDDSAF extrapolations are predictions based on sampling.

Mohs micrographic surgery and surgical excision for nonmelanoma skin cancer treatment in the Medicare population.

OBJECTIVES: To identify Medicare use rates of Mohs micrographic surgery (MMS) and surgical excision for the treatment of nonmelanoma skin cancer (NMSC) and to identify patient, lesion, and geographic characteristics associated with treatment type. DESIGN: A retrospective analysis of Medicare beneficiaries. SETTING: Surveillance, Epidemiology, and End Results database. PATIENTS: Patients undergoing MMS or other surgical intervention for the treatment of NMSC from January 1, 2001, through December 31, 2006. MAIN OUTCOME MEASURES: Surgical treatment, patient, and lesion characteristics. RESULTS: A total of 26,931 operations were performed for the treatment of NMSC from 2001 through 2006, of which 36.4% were MMS. Although the rate of surgical excision slightly increased during this period (1.8 vs 2.1 per 100 Medicare beneficiaries), the rate of MMS doubled (0.75 vs 1.5 per 100 Medicare beneficiaries). In 46.9% of facial lesions, MMS was performed, whereas MMS was used to treat 14.7% of total body lesions. Atlanta, Georgia, had the highest proportion of patients treated with MMS (45.1%); Louisiana had the lowest (11.0%). Age, race, lesion location, and area of country for patient treatment were significantly associated with MMS use (all P < .001). CONCLUSIONS: Surgical treatment of NMSC increased substantially from 2001 through 2006, primarily because of a doubling in the rate of MMS procedures. Significant differences in surgical rates, depending on patient age, race, lesion location, and geographic region, of treatment were found.

The hatchet and bilobed flaps revisited: shedding new light on traditional concepts.

BACKGROUND: The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results. OBJECTIVE: We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap. METHODS: We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years. RESULTS: Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity. CONCLUSIONS: We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

[Operative therapy of acral melanomas]. / Operative Therapie von akral lokalisierten Melanomen.

Acral lentiginous melanomas (ALM) represent 4-10% of cutaneous melanomas in white populations. Patients with ALM seem to have a poor prognosis, often due to late diagnosis. Micrographic surgery (3D-histology) is not seen as surgical procedure but more as histopathological technique. With micrographic surgery, continuously spreading ALM can be excised with smaller excision margins and good functional and cosmetic outcomes. In a recent study, 244 patients with ALM were compared using conventional histology versus 3D-histology. Clinical and surgical risk factors influence the prognosis of ALM. Tumor thickness and ulceration are the most important prognostic factors. 3D-histology with paraffin technique (optionally combined with immunohistological methods) can reduce excision margins and avoid local recurrences. Subungual melanomas represent only 2-3% of cutaneous melanomas in Caucasian and 20% in African or Asian skin type and are often clinically misdiagnosed. They are often localized on the thumb or great toe, which are most important for the function of the affected limb. The excision of subungual melanoma with 3D-histology and tumor-free excision margins including the nail matrix can be seen as a safe surgical strategy, which does not hazard the prognosis of the patient. Function and cosmesis of the finger or toe are preserved. Amputation in subungual melanoma is not recommended and should be reserved only for infiltrating melanomas with affection of the bone or joint.