Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study.

BACKGROUND: Mohs micrographic surgery efficiently treats skin cancer through staged resection, but surgeons' varying resection rates may lead to higher medical costs. OBJECTIVE: To evaluate the cost savings associated with a quality improvement. MATERIALS AND METHODS: The authors conducted a retrospective cohort study using 100% Medicare fee-for-service claims data to identify the change of mean stages per case for head/neck (HN) and trunk/extremity (TE) lesions before and after the quality improvement intervention from 2016 to 2021. They evaluated surgeon-level change in mean stages per case between the intervention and control groups, as well as the cost savings to Medicare over the same time period. RESULTS: A total of 2,014 surgeons performed Mohs procedures on HN lesions. Among outlier surgeons who were notified, 31 surgeons (94%) for HN and 24 surgeons (89%) for TE reduced their mean stages per case with a median reduction of 0.16 and 0.21 stages, respectively. Reductions were also observed among outlier surgeons who were not notified, reducing their mean stages per case by 0.1 and 0.15 stages, respectively. The associated total 5-year savings after the intervention was 92 million USD. CONCLUSION: The implementation of this physician-led benchmarking model was associated with broad reductions of physician utilization and significant cost savings.

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

Systematic Review of Technical Variations for Mohs Micrographic Surgery for Melanoma.

BACKGROUND: Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. OBJECTIVE: To define variations in published techniques for MMS for melanoma. METHODS AND MATERIALS: A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS. RESULTS: Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma. CONCLUSION: Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.

Mohs Micrographic Surgery for Advanced Centrofacial Tumors.

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.

Multidisciplinary Tumor Boards in Dermatologic Surgery.

BACKGROUND: Recent advances in diagnostic and therapeutic modalities have made oncologic care ever more challenging, and multidisciplinary tumor boards (MTBs) are increasingly being used as a forum to discuss and coordinate care for complex oncology patients. Literature on the use of MTBs specific to cutaneous oncology and dermatologic surgery remains limited. OBJECTIVE: To share our experiences with cutaneous oncology MTBs at the University of Vermont Medical Center (UVMMC). METHODS: We describe the formation, timing, participation, clinical discussion, case follow-up, and coordination of care of our MTBs. RESULTS: A log of all cases discussed at cutaneous oncology MTBs from August 2018 to August 2019 is presented as an example. Five specific cases are described in further detail to demonstrate critical components of multidisciplinary care. CONCLUSION: The MTBs at UVMMC has created a collaborative environment for providers in multiple specialties to jointly formulate and coordinate optimal treatment plans for difficult cases, particularly when treatment guidelines do not exist or are insufficient. Furthermore, MTBs can serve as an educational forum for all participants.

Expertise in Head and Neck Cutaneous Reconstructive Surgery.

BACKGROUND: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature. OBJECTIVE: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature. METHODS: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors. RESULTS: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%). CONCLUSION: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

Angiolymphoid hyperplasia with eosinophilia treated with Mohs micrographic surgery.

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.

Reconstruction of the nasal infratip, columella, and soft triangle.

BACKGROUND: Tumors of the soft triangle and distal nose are common, and the wounds created when removing them are among the more challenging defects to repair. OBJECTIVE: Reconstruction of the soft triangle, infratip, and columella requires attention to form and function beyond what is usually needed in cutaneous surgery. The complexities of the anatomy demand meticulous planning and surgical execution. In this review, the goal is to provide the cutaneous surgeon with a logical approach to repair this challenging region. METHODS: Skin grafts, composite grafts, local flaps, and pedicle flaps are presented with pearls and pointers. Cartilage grafting for stability is reviewed and detailed. A step-by-step approach allows the surgeon to plan appropriately and execute repairs with excellence. RESULTS: Ten cases are reviewed in sequential photo format to demonstrate successful reconstruction of operative wounds from this challenging region of the nose. CONCLUSION: The most distal nasal contours pose many challenges for reconstruction. Success depends on a good knowledge of anatomy, rigorous planning, and superior surgical skills. Skin grafts, composite grafts, local and interpolated flaps are all options that need to be considered when recreating the delicate folds and contours of this region. Cartilage support may be needed to maintain structural integrity. With care, excellent outcomes are predictably achieved.

Tangential shave removal of basal cell carcinoma.

OBJECTIVE: To determine the outcome of tangential shave removal (TS) of basal cell carcinoma (BCC) on the trunk and extremities. DESIGN: Cohort study of patients with multiple truncal BCC treated using TS in an academic dermatologic surgery practice. SETTING: Academic institution referral practice. PATIENTS: Individuals with BCC referred to the dermatologic surgery unit for ongoing therapy of multiple lesions. INTERVENTIONS: TS of amenable superficial and nodular BCCs with twice-annual follow-up. Lesions were removed using a scalpel as a uniform-depth mid-to-upper dermal shave and sent for routine pathology. Basic wound care was applied. PRIMARY OUTCOME MEASURES: Apparent cure rate and outcome of scars. RESULTS: One hundred eighty-two BCCs were treated in 19 individuals. Patients were followed for an average of 5.2 years. One lesion recurred. Three specimens had positive margins requiring further surgery. Scarring was acceptable and similar to what is observed with curettage and electrocoagulation. CONCLUSIONS: TS is a reasonable treatment for primary superficial and nodular BCC on the trunk and extremities.

Mohs micrographic surgery: How ACMS fellowship directors practice.

BACKGROUND: Mohs micrographic surgery (MMS) is widely employed in the removal of skin cancer. As this technique becomes more widely employed, it is useful to establish the patterns of care provided by American College of Mohs Surgery (ACMS)-approved fellowship directors. OBJECTIVE: To compile and analyze data collected annually by the ACMS to determine practice patterns and trends in MMS as performed by ACMS-approved fellowship directors. MATERIALS AND METHODS: A retrospective study of case logs from 50 fellowship directors obtained from the ACMS detailing case volume, type of cancer treated, location, lesion size, wound size, number of stages, referral percentage, and type of repairs performed. RESULTS: Annual case volume per surgeon has increased linearly. The incidence of squamous cell carcinoma treated using MMS is rising steadily. The size of lesions treated using MMS has decreased slightly over several decades, as has the number of stages of MMS taken per lesion. The majority of MMS performed by fellowship directors is for skin cancer on the face. Dermatologic surgeons perform most of their own reconstructions. Academic and private fellowship practice patterns are nearly identical. CONCLUSIONS: ACMS-approved fellowship directors use MMS mainly for facial skin cancers, and they perform most of their own reconstructions. Practice patterns for most fellowship directors are similar. Private fellowships and academic fellowships are similar in scope and practice.