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.

Colgajo este-oeste después de la cirugía micrográfica de Mohs / East-West Flap After Mohs Micrographic Surgery

La reparación de los defectos nasales distales producidos durante la cirugía micrográfica de Mohs representa un desafío para el cirujano. Existen múltiples técnicas por las cuales se puede optar para el cierre del defecto. Presentamos 3 casos en los que se realizó el colgajo este-oeste, un colgajo de avance, de fácil diseño, que consiste en un triángulo que cubre el defecto y un segundo triángulo de descarga con sus bases en la línea de desplazamiento. Con este colgajo se obtiene un óptimo resultado estético con un movimiento mínimo de los tejidos, preservando la arquitectura nasal y con líneas de sutura bien disimuladas

Repair of distal nasal defects resulting from Mohs micrographic surgery is a challenge, but surgeons can choose from a number of techniques. We present 3 cases in which an east-west flap was used to close the defect. The east-west flap is an easily conceived advancement flap that consists of a superior triangle used to cover the defect and an inferior triangle whose base is located along the advancement line. The flap results in an optimal cosmetic outcome and involves minimum movement of tissue (preserving the nasal architecture) and well-camouflaged suture lines

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.

Selfie de la cirugía de Mohs en España / A Selfie of Mohs Micrographic Surgery in Spain

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Descripción de las intervenciones quirúrgicas recogidas en el registro español de cirugía de Mohs (REGESMOHS) (2013-2015) / Characterization of Surgical Procedures in the Spanish Mohs Surgery Registry (REGESMOHS) for 2013-2015

Introducción: El Registro Español de Cirugía de Mohs recoge los datos de aplicación y resultados de esta técnica en España. Se describen los datos de las intervenciones realizadas desde el inicio del Registro en julio de 2013 a enero de 2016. Se analizan los datos de las cirugías tanto perioperatorios como intraoperatorios. Material y métodos: Estudio de cohortes prospectivo en el que participan 18 centros. Se recogen los datos de las intervenciones quirúrgicas como tipo de anestesia, técnica quirúrgica, ingreso hospitalario, número de estadios, manejo de factores de riesgo preoperatorios, tratamientos complementarios, tratamientos previos, tipo de tumor, tiempo empleado en la cirugía y complicaciones. Resultados: Se analizan 1.796 intervenciones quirúrgicas. El tumor intervenido con más frecuencia es el carcinoma basocelular (85,96%), seguido del carcinoma epidermoide (6,18%), lentigo maligno (2,81%) y dermatofibrosarcoma protuberans (1,97%). El 66,9% de los tumores eran primarios, el 19,2% recurrentes y el 13,9% persistentes. El tratamiento previo más frecuente fue quirúrgico. La cirugía de Mohs se realizó con más frecuencia bajo anestesia local (86,7%) y de forma ambulatoria (71,8%). En el 89,5% de los casos se utilizó la técnica de Mohs en congelación. El número de etapas requerido para alcanzar márgenes libres de tumor fue una en 56,45% de los pacientes, 2 en 32,1%, 3 en 7,1%, 4 en 2,7% y 5 o más en 1,8%. El propio dermatólogo reconstruyó el defecto en el 98% de los pacientes y la técnica reconstructiva más utilizada fue el colgajo (47,2%). Solo el 1,62% de los pacientes presentó alguna complicación intraoperatoria y la mediana de la duración de la cirugía fue 75 (p25:60-p75:100). Conclusión: Las características de los pacientes y tumores tratados son similares a las descritas en estudios de las mismas características en otras áreas geográficas. Existe un porcentaje mayor de lentigo maligno y dermatofibrosarcoma protuberans. La reconstrucción la realiza el dermatólogo con más frecuencia que en otras series. El tiempo de utilización de quirófano no es mucho mayor que para otras técnicas y la tasa de complicaciones intraoperatorias es muy reducida (AU)

Introduction: The Spanish Mohs Surgery Registry is used to collect data on the use and outcomes of Mohs micrographic surgery (MMS) in Spain. The aim of this study was to describe perioperative and intraoperative data recorded for MMS procedures performed between July 2013 (when the registry started) and January 2016. Material and methods: Prospective cohort study of data from 18 hospitals. The data collected included type of anesthesia, surgical technique, hospital admission, number of Mohs stages, management of preoperative risk factors, additional treatments, previous treatments, type of tumor, operating time, and complications. Results: Data were available for 1796 operations. The most common tumor treated by MMS was basal cell carcinoma (85.96%), followed by squamous cell carcinoma (6.18%), lentigo maligna (2.81%), and dermatofibrosarcoma protuberans (1.97%). Primary tumors accounted for 66.9% of all tumors operated on; 19.2% of tumors were recurrent and 13.9% were persistent. The most common previous treatment was surgical. MMS was mostly performed under local anesthesia (86.7% of cases) and as an outpatient procedure (71.8%). The frozen section technique was used in 89.5% of cases. One stage was needed to achieve tumor-free margins in 56.45% of patients; 2 stages were required in 32.1% of patients, 3 in 7.1%%, 4 in 2.7%, and 5 or more in 1.8%. The defect was reconstructed by the dermatologist in 98% of patients and the most common technique was flap closure (47.2%). Intraoperative complications were recorded for just 1.62% of patients and the median (interquartile range) duration of surgery was 75 (60-100) minutes. Conclusion: The characteristics of the patients and tumors treated by MMS are similar to those reported for similar studies in other geographic areas. Lentigo maligna and dermatofibrosarcoma protuberans accounted for a higher proportion of cases in our series, and repair of the surgical defect by a dermatologist was also more common. Operating times in MMS are not much longer than those reported for other procedures and the rate of intraoperative complications is very low (AU)

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.

Management of high-risk and advanced basal cell carcinoma

Despite that basal cell carcinoma (BCC) is curative in the vast majority of cases, some patients are at high risk of recurrence and, in a few patients, lesions can progress to a point unsuitable for local therapy and prognosis is quite poor. The aim of the present work is to review clinical and pathologic characteristics as well as classical and new treatment options for high-risk, metastatic and locally advanced BCC. Surgery and radiotherapy remain the selected treatments for the majority of high-risk lesions. However, some patients are located on a blurry clinical boundary between high-risk and locally advanced BCC. Treatment of these patients is challenging and need an individualized and highly specialized approach. The treatment of locally advanced BCC, in which surgery or radiotherapy is unfeasible, inappropriate or contraindicated, and metastatic BCC has changed with new Hedgehog pathway inhibitors of which vismodegib is the first drug approved by FDA and EMA (AU)

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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.

Cera para huesos en la cirugía dermatológica / Bone Wax in Dermatologic Surgery

La cera para huesos es un material inerte y maleable que se utiliza como hemostático en los defectos óseos. La curación por segunda intención es una opción terapéutica en determinados casos después de la cirugía dermatológica. En las heridas quirúrgicas profundas, con exposición de distintos tejidos como hueso o cartílago, ciertos apósitos pueden adherirse al tejido de granulación. Esto dificulta y hace muy dolorosa la curación posterior. En estos casos la aplicación de un molde con cera para huesos proporciona un microambiente oclusivo hemostático ideal que favorece la cicatrización por segunda intención (AU)

Bone wax is an inert, malleable material used as a hemostatic agent in treating surgical defects. Healing by secondary intention is an appropriate approach for certain situations in dermatologic surgery. When surgical wounds are deep enough for such tissues as bone or cartilage to be exposed, dressings may adhere to granulation tissue, making removal and subsequent wound care difficult and painful. In such cases bone wax can be molded around deep tissues to create an ideal occlusive, hemostatic microenvironment that facilitates second-intention wound healing (AU)

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.