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Mohs surgery

Mohs surgery
Literature review current through: Jan 2024.
This topic last updated: Jan 17, 2023.

INTRODUCTION — Mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue [1-4]. In contrast to standard excision, in which only a small portion of the margins are evaluated, in MMS, specimens are cut in horizontal sections that allow the evaluation of the entire peripheral and deep margins of the tumor.

The most common malignancies treated with MMS are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). MMS is also used to remove other skin malignancies such as dermatofibrosarcoma protuberans (DFSP), microcystic adnexal carcinoma, extramammary Paget disease (EMPD), and lentigo maligna.

The MMS technique and its indications will be discussed in this topic review. Alternative treatments for skin tumors are discussed separately.

(See "Treatment of basal cell carcinomas at high risk for recurrence".)

(See "Recognition and management of high-risk (aggressive) cutaneous squamous cell carcinoma".)

(See "Dermatofibrosarcoma protuberans: Treatment".)

(See "Staging, treatment, and surveillance of locoregional Merkel cell carcinoma".)

(See "Microcystic adnexal carcinoma".)

(See "Sebaceous carcinoma".)

(See "Atypical fibroxanthoma".)

(See "Lentigo maligna: Clinical manifestations, diagnosis, and management".)

HISTORICAL PERSPECTIVE — The original technique, developed by Frederic Mohs in the 1930s, was called "fixed-tissue technique" or chemosurgery [1,2,5]. It involved the overnight application of a zinc chloride paste to the tumor, which produced tissue necrosis but retained the microscopic architecture. The devitalized, preserved tissue was subsequently excised in a saucer-shaped layer and marked with colored dyes for orientation and correlation on a map. The specimens were then manually flattened, sectioned in the horizontal plane, and stained for histologic examination. In areas of residual tumor, zinc chloride was reapplied overnight and the process repeated until clear margins were achieved.

In the following years, Mohs surgery evolved from the fixed-tissue to a "fresh-tissue technique" that used frozen sections of the excised tissue and was initially employed to treat eyelid cancers with a five-year cure rate of 100 percent [2,4]. The fresh-tissue technique allows single-day excision and repair of the surgical defect in most cases and has become the standard technique for Mohs surgery [3].

SURGICAL TECHNIQUE

Overview — Mohs micrographic surgery (MMS) is performed under local anesthesia by a dermatologic surgeon formally trained in dermatology and fellowship trained in MMS, cutaneous oncology, and dermatologic surgery. The tumor is excised at an oblique angle, and the beveled specimen is mapped for orientation, sectioned, and processed into frozen, horizontal sections for microscopic evaluation of the entire peripheral and deep margins. Residual tumor identified on histologic examination is marked on a pictorial map to guide the removal in subsequent stages until negative margins are achieved. Immediate reconstruction is performed in most cases.

Excision and mapping — The clinical margins of the biopsy-proven skin cancer are carefully marked with a surgical pen using bright illumination. The skin is prepared with an antiseptic, and the site is anesthetized with a local anesthetic (eg, lidocaine 1% combined with epinephrine 1:100,000 for vasoconstriction). The tumor can be debulked with a semi-sharp instrument (curette) for a better delineation of the tumor extent. Curetting, however, is not effective for morpheaform basal cell carcinoma (BCC) or other nonfriable tumors [6].

A saucerized or beveled excision of the tumor is performed with a margin of normal-appearing tissue using a scalpel angled at 45 degrees to the skin surface. The margin and depth of tissue initially excised depend upon tumor features and histologic subtype. Narrow margins of 1 to 2 mm are taken in sensitive areas, whereas larger margins may be necessary for bulky or recurrent tumors.

For superficial tumors, the initial excision is shallow, whereas for deeply infiltrating cancers the excision depth may extend to the subcutaneous tissue. Before removing the tissue, reference nicks are placed extending from the tissue onto wound edges (eg, at 12, 3, 6, and 9 o'clock positions) to maintain precise anatomic orientation. A diagram (Mohs map) of the surgical defect with anatomic landmarks and location of reference nicks is created (picture 1).

The excised tissue and Mohs map are transferred to the Mohs laboratory for frozen tissue processing with careful attention to preserving tissue orientation. The surgical defect is bandaged, and the patient awaits margin examination results [7-10].

Residual tumor identified on histologic examination is marked on a pictorial map to guide the removal in subsequent stages until negative margins are achieved.

Frozen tissue processing — The excised tissue is processed in an adjacent Mohs laboratory by a specially trained histotechnician under the supervision of the Mohs surgeon [11].

The tissue is first subdivided into smaller pieces as necessary to fit onto a cryostat chuck and microscope slide. The pieces are sequentially numbered, and cut edges are color coded with two or more dyes for accurate orientation and identification. The subdivision, numbering, and inking pattern are carefully recorded on the Mohs map.

To allow the complete examination of the peripheral and deep surgical margins, the angled skin edge is flattened, and the tissue is inverted and oriented such that the deep margin and skin edge are aligned in a horizontal plane. Tissue is cut in a cryostat in the horizontal plane into frozen sections 5 to 7 microns thick. Sectioned tissue is then fixed and stained with routine hematoxylin and eosin or toluidine blue.

Histologic examination — The surgeon evaluates the frozen section margins for residual skin cancer and marks subclinical tumor extensions on the map. A second layer of tissue is excised from the wound at the exact location of the residual tumor with preservation of uninvolved tissue. The process is repeated until a tumor-free plane is achieved (picture 2) [8].

Immunostaining — In high-risk skin cancers, immunohistochemical staining may be required for the evaluation of the surgical margins in conjunction with standard staining of frozen sections [12-14]. Rapid immunostains for frozen sections are available, including cytokeratins for squamous cell carcinoma (SCC), melan-A (MART-1), microphthalmia transcription factor (MITF) for lentigo maligna, and CD34 for dermatofibrosarcoma protuberans (DFSP).

Technical pitfalls — The success of MMS can be compromised by pitfalls occurring in any of the many steps of the procedure, including [15]:

Debulking – The pre-excision curettage may remove tissue in a nonuniform way, creating jagged margins and floaters.

Excising – A bevel angle >45 degrees may interfere with tissue flattening and require relaxing incisions that can interrupt the margin continuity and confuse orientation.

Creating the map – There is no standardized way to create a map. Hand-drawn pictures are used by most surgeons to map and orient specimens, although this method may not provide a reliable size and shape of the excised area. Alternative maps such as photographs and pre-drawn diagrams may also be used at the discretion of the surgeon.

Subdivision and inking – Tissue lacerations may occur during sectioning and be mistaken for hash marks; ink may be placed on the wrong margin or run over the wrong section.

Tissue processing – Pitfalls can also occur during flattening, freezing, sectioning, slide fixation, and staining.

RECONSTRUCTION — Once Mohs margins are free of cancerous cells, the defect is analyzed to determine the optimal repair technique. Tumor characteristics, location and size of the defect, patient comorbidities, and aesthetic considerations guide the choice of the repair technique.

Many Mohs surgical defects can be repaired in a linear manner. Superficial wounds in concave areas such as the medial canthus heal well by second intention. Second intention healing may also be an option for skin cancers at high risk for recurrence in which reconstruction may make tumor surveillance difficult.

Larger defects in anatomically sensitive areas require repair with a full-thickness skin graft or local flap.

For complex cases with defects involving vital structures, collaboration with a reconstructive surgeon specializing in oculoplastics, otorhinolaryngology, or plastic surgery may be necessary [16,17].

INDICATIONS

General indications — Mohs micrographic surgery (MMS) is primarily indicated for the treatment of locally aggressive tumors at high risk for recurrence. The high-risk nature of a cutaneous tumor is determined by tumor characteristics, patient risk factors [18], and anatomic site (table 1).

Certain anatomic locations offer less resistance to tumor invasion and are associated with deeper and more irregular growth patterns. High-risk locations include [19]:

The embryonic fusion planes – The medial canthus, paranasal area, alar crease, philtral ridge

Skin overlying cartilage such as the pinna of the ear or nasal tip

Recurrent tumors in which the growth pattern may be unpredictable because of scarring and surgical planes from previous surgery are also an indication for MMS.

Tumors treated successfully with Mohs surgery have the following characteristics:

Tumor amenable to interpretation with frozen sections

Tumor growth contiguous for microscopic mapping of subclinical extension

Removal of primary tumor with narrow margins adequate

Specific indications

Basal cell carcinoma – High-risk primary basal cell carcinomas (BCC) and recurrent BCC are the most common tumors treated with MMS [20-22]. High-risk BCCs include tumors ≥6 mm located in high-risk areas (central face, nose, lips, eyelids, eyebrows, periorbital skin, chin, mandible, ears, preauricular and postauricular areas, temples, hands, feet); ≥10 mm in other areas of the face (cheeks, forehead, scalp, and neck); tumors ≥20 mm on trunk or limbs; or tumors with aggressive pathologic features [23]. (See "Treatment of basal cell carcinomas at high risk for recurrence", section on 'Features associated with high risk for recurrence'.)

Squamous cell carcinoma – Squamous cell carcinoma (SCC) is the second most common skin cancer treated with MMS [22,24]. High-risk SCCs (eg, tumors ≥20 mm, involving high-risk areas of the face such as ears and lips, or tumors showing perineural invasion or poor histologic differentiation) are effectively treated with MMS [23,25]. (See "Treatment and prognosis of low-risk cutaneous squamous cell carcinoma (cSCC)", section on 'High-risk lesions'.)

Dermatofibrosarcoma protuberans – Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive, soft-tissue sarcoma most often occurring on the trunk and extremities of young to middle-aged adults. Because the microscopic extension of DFSP is unpredictable, large defects and numerous tissue sections are often required to achieve negative margins. Reconstruction frequently is delayed by the need for excision of a "final" margin that is sent for paraffin-embedded permanent sections and immunohistochemistry. Some surgeons perform a modified "slow" MMS that uses paraffin-embedded permanent sections. However, in contrast to the frozen section processing time of one to two hours, paraffin sections require a minimum of 24 to 48 hours. (See "Dermatofibrosarcoma protuberans: Epidemiology, pathogenesis, clinical presentation, diagnosis, and staging".)

Microcystic adnexal carcinoma – Microcystic adnexal carcinoma is a rare tumor of sweat glands that typically occurs in the head and neck region of older adults. This deeply infiltrative tumor with frequent perineural invasion has a locally aggressive behavior and a high tendency to recur after wide local excision (WLE). Recurrence rates with MMS range from 0 to 12 percent [26,27]. (See "Microcystic adnexal carcinoma".)

Extramammary Paget disease – Extramammary Paget disease (EMPD) is a slow-growing, rare apocrine carcinoma that usually occurs on the genitalia and less commonly the axilla. The recurrence rate is high after WLE, despite negative margins. Observational studies indicate that treatment with MMS may be associated with lower recurrence rates [28-30]. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)

Melanoma – The use of Mohs surgery for treatment of melanoma remains controversial. There are no clinical trials comparing WLE with MMS. In a consecutive series of 625 patients with head and neck melanoma treated with MMS and followed up for a mean of 58 months, recurrence, metastasis, and disease-specific survival rates were similar or better than historical controls treated with WLE [31]. Similar results were observed in a single-institution retrospective study comparing the outcome of 277 patients with melanoma in situ treated with WLE with that of 385 patients treated with MMS [32]. After a median follow-up time of 8.6 years (range 0.2 to 37 years), the overall recurrence rates and the melanoma-specific mortality rates were not significantly different for patients treated with WLE and those treated with MMS (5.7 versus 1.8 percent and 3.4 versus 0.7 percent, respectively). (See "Surgical management of primary cutaneous melanoma or melanoma at other unusual sites", section on 'Head and neck'.)

Lentigo maligna – MMS may be a treatment option for lentigo maligna, a type of melanoma in situ, because of its poorly defined clinical borders, unpredictable subclinical extension, head and neck location requiring tissue conservation, and propensity for recurrence. However, margin assessment with frozen sections can be problematic in lentigo maligna [15]. In a study of 167 patients with melanoma in situ or lentigo maligna, approximately 5 percent of samples with negative margins on frozen sections were positive on permanent sections [33]. To overcome the limitations of frozen sections, some Mohs surgeons excise and map lentigo maligna with the Mohs technique but process the tissue with en face paraffin-embedded permanent sections ("slow" MMS). Special stains may also be used to improve the interpretability of MMS frozen section for melanoma. (See "Lentigo maligna: Clinical manifestations, diagnosis, and management".)

Other tumors – Mohs surgery has been used to treat many other skin tumors, including sebaceous carcinoma, Merkel cell carcinoma, atypical fibroxanthoma, verrucous carcinoma, keratoacanthoma, adenoid cystic carcinoma, angiosarcoma, and leiomyosarcoma. (See "Sebaceous carcinoma" and "Staging, treatment, and surveillance of locoregional Merkel cell carcinoma" and "Atypical fibroxanthoma" and "Keratoacanthoma: Epidemiology, risk factors, and diagnosis" and "Head and neck sarcomas", section on 'Angiosarcoma'.)

Detailed criteria for appropriate use of MMS covering 270 clinical scenarios commonly encountered in clinical practice have been developed by the American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery [34].

ADVANTAGES AND DISADVANTAGES

Advantages — The Mohs technique offers several advantages over standard surgical excision and pathology processing (table 2):

Better clinicopathologic management of skin cancer. One clinician performs the excision of tumor, oversight of tissue processing, and interpretation of frozen sections.

Control of the entire surgical margin by using horizontal sections. In contrast, standard excision uses "bread loaf" vertical sectioning, which only permits the evaluation of a small portion of the tumor margins.

Maximal preservation of normal tissue in cosmetically and anatomically sensitive areas (around the eyes, nose, lips, and ears).

Immediate reconstruction of the defect in most cases.

Lower recurrence rates than standard excision for high-risk tumors (table 3) [26,35-38].

Disadvantages — Mohs micrographic surgery (MMS) is an extremely labor-intensive procedure. It requires a highly qualified clinician with expertise in the management of high-risk skin cancers, an experienced histotechnician with specific training in Mohs frozen tissue processing, a fully certified Mohs laboratory, and well-trained nursing staff.

MMS is also a time-consuming process that requires patient cooperation and understanding. A typical procedure lasts two to four hours, and more complicated cases can take longer. A significant amount of the total time is spent on histologic preparation and analysis. If the patient has serious and labile medical problems or is unwilling to undergo surgery, nonsurgical alternatives such as radiation may be warranted.

LIMITATIONS — In some instances, complete tumor eradication is not possible with Mohs micrographic surgery (MMS). This may occur when an aggressive skin cancer invades a vital structure and further excision with local anesthesia alone is not feasible in an office setting. In those cases, referral to a specialized surgical oncologist is necessary.

Skin cancers with perineural invasion, such as squamous cell carcinomas (SCC), can recur despite achieving tumor-free margins on Mohs frozen sections. A break in tumor continuity can result in a false-negative Mohs margin and occurs most frequently in recurrent tumors with scar tissue and fibrosis obscuring residual tumor. False-negative Mohs margins can also occur in tumors with potential for skip areas such as superficial basal cell carcinomas (BCC).

Frozen section slides may be more difficult to interpret than paraffin-embedded permanent sections [39]. Dense inflammation can be confused with cancer cells or can mask cancerous tissue. Differentiating a BCC from a benign basaloid proliferation or an adnexal structure (eg, trichoepithelioma or tangentially sectioned hair follicle) may be difficult. Pseudocarcinomatous hyperplasia (downward growth of irregular columns of prickle cells into the dermis occurring in wound healing) or tangential sectioning of the epidermis may be mistaken for residual SCC.

In some cases, the tumor cannot be reliably identified on frozen sections, and accurate diagnosis requires permanent sections and immunohistochemical staining, with delayed wound repair. As an example, residual cells of dermatofibrosarcoma protuberans cannot be clearly differentiated from scattered spindle cells in normal dermis or scar tissue. (See "Dermatofibrosarcoma protuberans: Treatment", section on 'Mohs micrographic surgery'.)

Consultation with a dermatopathology colleague face to face or via telepathology or additional use of paraffin-embedded permanent sections [40] can be useful for difficult or rare tumors [41].

COMPLICATIONS — Mohs micrographic surgery (MMS) is generally a safe procedure with a low risk of intra- and postoperative complications, which include:

Bleeding and/or hematoma

Infection of the wound site

Flap or graft necrosis following repair

Dehiscence

In meta-analyses, prospective, and retrospective studies, the overall complication rate ranges from 1.6 to 3 percent [42-46]. Wound infection has been reported in 0.1 to 2.3 percent of patients undergoing MMS [45,47-49]. Immunosuppression does not seem to be associated with an increased rate of wound infection [50].

In a multicenter, prospective cohort study including nearly 21,000 patients treated with MMS, adverse events were reported in 149 cases (0.72 percent) [51]. The most common were infections (0.44 percent), dehiscence and partial or full necrosis (0.15 percent), and bleeding and hematoma (0.11 percent). Four adverse events were serious and resulted in hospitalization but not death.

Oral anticoagulants and antiplatelet agents increase the risk of perioperative complications, as illustrated below. Novel oral antiplatelet and anticoagulant agents (eg, rivaroxaban, apixaban, dabigatran) are increasingly used among patients; however, there are few studies evaluating their effects on bleeding for outpatient surgical procedures [52,53].

In a meta-analysis of patients undergoing cutaneous surgery, severe local complications (hematoma, graft or flap failure, hemorrhage, or dehiscence) occurred in 1.3 percent of patients taking aspirin and 5.7 percent of patients taking warfarin [44]. The risk of complications among patients taking warfarin was seven times higher than controls (odds ratio [OR] 6.7, 95% CI 3.0-14.7).

A subsequent meta-analysis including 957 patients undergoing cutaneous surgery while on anticoagulant therapy with aspirin, warfarin, or clopidogrel found an increased risk of mild to moderate (OR 3.2, 95% CI 1.4-7.1) or severe (OR 14.8, 95% CI 2.7-80.4) postoperative bleeding in patients taking warfarin [54]. The risk of postoperative bleeding was not increased in patients taking aspirin.

In a prospective study of 1911 patients undergoing MMS or routine cutaneous surgery (including 731 patients who were on anticoagulant therapy with aspirin, warfarin, or clopidogrel), bleeding complications occurred in less than 1 percent and were associated with the use of warfarin (OR 10, 95% CI 3.5-28.3) or clopidogrel (OR 4.5, 95% CI 1.1-17.3) and with the type of closure (partial, flaps, or graft) [42].

In a retrospective study of 743 patients, the risk of intra- or postoperative hemorrhage, hematoma, flap/graft necrosis, or dehiscence was higher in patients taking clopidogrel-containing regimens than in patients taking aspirin monotherapy (OR 6, 95% CI 1.3-27.6) or no anticoagulants (OR 27.8, 95% CI 1.6-474) [43].

In a retrospective study of 31 patients undergoing cutaneous surgery, including 27 taking dabigatran and 4 rivaroxaban, there was only one minor bleeding complication [52].

PREOPERATIVE EVALUATION AND MANAGEMENT

Preoperative consultation — An office visit with the patient is necessary before Mohs micrographic surgery (MMS) to:

Review the patient's medical history and the use of medications, including anticoagulants and nonsteroidal anti-inflammatory drugs, or cardiac devices; evaluate the need for antibiotic prophylaxis; assess tobacco and alcohol use.

Perform a physical examination of the skin cancer site, surrounding tissue, and draining lymph nodes.

Review the diagnosis of skin cancer, treatment options, and advantages and disadvantages of MMS.

Discuss the surgery's complications, including infection, bleeding, hematoma or seroma, dehiscence or necrosis following repair, scarring, tumor recurrence, and nerve injury. (See 'Complications' above.)

Review the preoperative biopsy before Mohs surgery to confirm the histologic diagnosis of skin cancer.

Prior to obtaining the informed consent for Mohs surgery, the patient is asked to verify the site or location of the skin cancer using a mirror if necessary. A photograph of the skin cancer site taken at the time of the biopsy is helpful in accurately identifying the correct location [6,55].

Antibiotic prophylaxis — Most MMS procedures do not require antibiotic prophylaxis. However, antibiotic prophylaxis is indicated in the following situations (algorithm 1) [56]:

Patients who are at high risk for surgical-site infection, based on the site (lips, ears, nose, groin, or lower extremities) or technique used (skin flaps or grafts).

Patients at high risk for infective endocarditis or hematogenous total joint or artificial heart valve infection if surgery involves the oral mucosa [57,58]. (See "Prevention of prosthetic joint and other types of orthopedic hardware infection", section on 'Following hardware placement' and "Prevention of endocarditis: Antibiotic prophylaxis and other measures".)

If the surgical site is infected before the procedure. In this case, cultures should be obtained, aggressive treatment initiated with full-dose antibiotics against Staphylococcus aureus and Streptococcus pyogenes, and prophylaxis for infective endocarditis or hematogenous total joint infection provided.

If there is an increased risk of methicillin-resistant S. aureus (MRSA) infection. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections".)

Nasal carriage of S. aureus is a proven endogenous risk factor for surgical-site infection [59,60]. Among patients undergoing MMS, prophylactic nasal decolonization and skin decontamination have been shown to reduce the rate of postoperative infections [61]. Moreover, topical decolonization may be more effective than prophylactic oral antibiotics in preventing surgical-site infection. In a randomized trial including 179 patients undergoing MMS who had positive nasal swab for S. aureus, the rate of postsurgical infection was 9 percent in the group receiving prophylactic oral antibiotics (cephalexin 1000 mg 30 to 60 minutes before surgery and six hours after) and 0 percent in the group receiving topical prophylaxis (intranasal mupirocin twice daily combined with once-daily head, neck, and body wash with 4% chlorhexidine gluconate solution for five consecutive days preoperatively) [62].

Anticoagulants — Anticoagulation is generally safe in patients undergoing Mohs micrographic surgery (MMS) [63]. The rate of severe complications among patients undergoing MMS while on oral anticoagulants or antiplatelet agents is low, and complications are not life threatening and limited to the wound site [42-44,63]. (See 'Complications' above.)

In contrast, the risk of thromboembolic events increases even after a short period of suspension of anticoagulant therapy. (See "Perioperative management of patients receiving anticoagulants", section on 'Estimating thromboembolic risk' and "Perioperative management of patients receiving anticoagulants", section on 'Overview of our approach'.)

Given the balance of risks and benefits, we suggest that anticoagulant therapy be continued for patients undergoing Mohs surgery [64,65]. In patients taking warfarin, the international normalized ratio (INR) should be maintained within the therapeutic range. A study has indicated a significantly increased risk of postoperative bleeding complications, including hematoma formation, with the use of newer anticoagulants (apixaban, dabigatran, rivaroxaban) alone and in combination with aspirin [66]. However, the bleeding complications were minor and easily managed. Therefore, these medications should not be discontinued during the perioperative period.

Management of procedural anxiety — In cutaneous surgery, there are different methods, pharmacologic and nonpharmacologic, to manage patients' anxiety [67,68]. In select patients, an oral anxiolytic is used to reduce procedural-related anxiety. Oral midazolam, a short-acting benzodiazepine, was reported as safe and effective in patients undergoing MMS in a randomized trial [69] and in a series of pediatric patients undergoing dermatologic surgical procedures [70]. Other benzodiazepines (eg, lorazepam, alprazolam) may also be used; however, an understanding of their pharmacology is needed for appropriate and effective administration. Care should be taken in older adult patients who are at significant risk for falls and subsequent complications.

Among nonpharmacologic methods, patient education using preoperative images, videos, or telephone calls prior to MMS did not reduce procedural anxiety compared with nonintervention in three small, randomized trials [71-73]. Listening to music provided inconsistent results in two studies [71,74].

The management of procedural anxiety is reviewed in greater detail elsewhere. (See "Acute procedural anxiety and specific phobia of clinical procedures in adults: Treatment overview".)

Immunotherapy considerations — In recent years, advances in the treatment of various cancers include immunotherapy (eg, programmed cell death-1 [PD-1] and cytotoxic T lymphocyte-associated antigen 4 [CTLA-4] inhibitors) and targeted therapy (eg, BRAF, MEK, epidermal growth factor receptor [EGFR] inhibitors). While there are limited data available on their effects on surgical procedures, adverse events for some include bleeding and poor wound healing. In a multicenter, phase II study of 111 patients on ibrutinib (a Bruton's tyrosine kinase inhibitor used for the treatment of hematologic malignancies), more than 2 percent had serious bleeding events [75]. Two cases of excessive ecchymosis after MMS have also been reported [76].

Vascular endothelial growth factor receptor (VEGFR) inhibitors, notably bevacizumab, are associated with thrombocytopenia and poor wound healing. In two randomized trials, 10 out of 75 patients (13 percent) had a bleeding or wound-healing complication after undergoing major surgery while on bevacizumab compared with 3.4 percent in the control group [77].

Immune checkpoint inhibitors, including antibodies to PD-1 and CTLA-4, are rarely associated with thrombocytopenia and account for less than 1 percent [78]. There are no significant risks of bleeding or wound-healing complications with BRAF and MEK inhibitors [79,80].

Quality of life considerations — Quality of life and patient satisfaction are increasingly important treatment outcomes for Mohs surgery. In the preoperative consultation, eliciting patient expectations with healing and cancer worry should be considered for patient-centered care [81,82]. Studies using a patient-reported outcome measure validated in the skin cancer population, such as the FACE-Q Skin Cancer, have shown that factors such as female sex, tumor location in central areas of the face, and complex repairs are associated with lower postoperative appearance satisfaction and greater appearance-related distress following surgery [83,84]. Symptoms related to surgery, such as sensitivity, numbness, and tightness, also persist postoperatively in a subset of patients, emphasizing the importance of additional counseling for select patients [85].

Patients aged 85 years and older — The 85 years and older population is the fastest growing segment of the United States population. Due to the predilection for keratinocyte carcinoma to develop in the older population, consideration of tumor biology, patient preference, treatment duration, and life expectancy is warranted for informed decision making [86]. Studies have shown that Mohs surgery is well tolerated in this population and that older patients undergoing Mohs surgery have high functional status [87-90].

In a single-institution study including 488 patients aged ≥85 years presenting for treatment of nonmelanoma skin cancer (NMSC), patients who underwent MMS survived longer than those who did not pursue MMS, despite having similar rates of comorbidities (hazard ratio [HR] 0.63, 95% CI 0.46-0.86, after adjusting for age, sex, anatomic site of tumor/risk for recurrence, and comorbidity score, as assessed with the age-adjusted Charlson Comorbidity Index) [18]. The study concluded that although age and comorbidities were generally associated with life expectancy in this patient population, other factors (eg, functional status) may have contributed to a longer survival in the group undergoing MMS.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Mohs surgery".)

SUMMARY AND RECOMMENDATIONS

Definition – Mohs surgery is a specialized surgical technique for removing high-risk skin cancers that provides high cure rates and maximal tissue preservation. (See 'Introduction' above.)

Surgical technique – In Mohs micrographic surgery (MMS), tumors are excised under local anesthesia at an oblique angle and mapped on a diagram of the surgical defect. The excised tissue is processed into frozen horizontal sections that allow the histologic evaluation of the entire peripheral and deep margins. Subclinical tumor extensions are precisely marked on the map. A second layer of tissue is subsequently excised at the exact location of the residual tumor with preservation of uninvolved tissue. The process is repeated until negative margins are achieved. Immediate reconstruction is performed in most cases. (See 'Overview' above.)

Indications – Mohs surgery is most commonly performed to treat basal cell and squamous cell carcinomas (BCC and SCC) at high risk of recurrence. Mohs surgery is also indicated for other skin malignancies such as dermatofibrosarcoma protuberans (DFSP), microcystic adnexal carcinoma, and extramammary Paget disease (EMPD), and for lentigo maligna. (See 'Indications' above and "Treatment of basal cell carcinomas at high risk for recurrence" and "Recognition and management of high-risk (aggressive) cutaneous squamous cell carcinoma" and "Dermatofibrosarcoma protuberans: Epidemiology, pathogenesis, clinical presentation, diagnosis, and staging" and "Microcystic adnexal carcinoma" and "Lentigo maligna: Clinical manifestations, diagnosis, and management".)

Advantages of Mohs surgery – Mohs surgery offers several advantages over standard surgical excision, including lower recurrence rates for high-risk tumors, maximal tissue preservation in cosmetically and anatomically sensitive areas, and immediate reconstruction in most cases (table 2). However, Mohs surgery is a labor-intensive and time-consuming process that requires a highly qualified clinician with expertise in the management of high-risk skin cancers, a fully certified Mohs laboratory, and specifically trained histotechnician and nursing staff. (See 'Advantages and disadvantages' above.)

Complications – Mohs surgery is generally a safe procedure with overall complication rates lower than 3 percent. (See 'Complications' above.)

Antibiotic prophylaxis – Antibiotic prophylaxis is not needed in most Mohs surgery procedures. However, antibiotic prophylaxis is indicated for patients at high risk of surgical-site infection; patients at high risk of infective endocarditis or hematogenous total joint infection, if surgery involves the oral mucosa; or if the surgical site is infected before the procedure. (See 'Antibiotic prophylaxis' above.)

Anticoagulation – Anticoagulation is generally safe in patients undergoing MMS. In patients taking warfarin, the international normalized ratio (INR) should be maintained within the therapeutic range. The reported rates of local complications among patients undergoing Mohs surgery while on anticoagulants range from 1 to 3 percent. In contrast, the risk of thromboembolic events increases even after a short period of suspension of anticoagulant therapy. Given the balance of risks and benefits, we suggest that anticoagulant therapy be continued for patients undergoing Mohs surgery. (See 'Anticoagulants' above and "Perioperative management of patients receiving anticoagulants".)

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Topic 13708 Version 23.0

References

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