- Author: Shang I Brian Jiang, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Mohs surgery is a surgical technique used to treat various skin cancers that allows precise microscopic control of the margins by utilizing tangentially cut frozen-section histology. Mohs surgery has become the treatment of choice for most skin cancers on the head and neck as well as for recurrent or histologically aggressive lesions.
A retrospective study by Reeder et al of the use of Mohs surgery from 1995 to 2010 in the United States found an upward trend in the technique’s utilization but a low percentage of skin cancers (10% on average) being treated with this surgery. The study, which drew data from the National Ambulatory Medical Care Survey, also indicated that Mohs surgery most often involved the head and neck region.
See the list below:
- Fresh-tissue technique: Treatment of choice for most skin cancers on the head and neck as well as for recurrent or histologically aggressive lesions; cutaneous tumors are excised at a 45° angle with mapping and subsequent identification of residual cancer using light microscopy
- Fixed-tissue technique (chemosurgery) (used infrequently): Similar to the fresh-tissue technique, but tissue fixation is achieved with a zinc chloride paste and takes place before excision; this process eliminates the need for anesthesia and creates a blood-free surgical field
Indications for Mohs surgery
All recurrent basal cell carcinomas (BCCs) or high-risk primary tumors with 1 or more of the following features are candidates for Mohs surgery:
- Aggressive histologic growth pattern
- Location in anatomic sites at which conventional treatment modalities have a higher potential risk of recurrence
- Location at anatomic sites that require tissue conservation for optimal reconstruction
- Other features
Squamous cell carcinomas (SCCs) at high risk for local recurrence or metastasis are best treated with Mohs surgery. High-risk criteria include the following:
- Large size (>2 cm)
- Depth of invasion (>4 mm)
- Recurrent or incompletely excised tumors
- Histologic subtype, including undifferentiated, poorly differentiated, acantholytic (pseudoglandular)
- Perineural or perivascular invasion
- Rapid growth
- Long duration
- Tumors in patients with immunosuppression
- Radiation-induced lesions
- Certain genodermatoses (inherited skin conditions)
- Certain anatomic locations (eg, scalp, periorbital/canthal region, columella, lips, lower extremities, nail bed and matrix)
- Other sites (eg, previously irradiated skin, thermal/radiation scars)
Other unusual cutaneous tumors with aggressive features or highly cosmetically sensitive locations are candidates for Mohs Surgery, including but not limited to the following:
- Verrucous carcinoma
- Extramammary Paget disease
- Microcystic adnexal carcinoma
- Dermatofibrosarcoma protuberans
- Sebaceous carcinoma
- Atypical fibroxanthoma
- Malignant melanoma
Disadvantages and limitations of Mohs surgery
Disadvantages of Mohs surgery include the following:
- The procedure may become tedious and prolonged for the patient; especially if the case is difficult or complex.
- An inability to remove a large or difficult tumor in one day may preclude immediate reconstruction after complete excision.
- The procedure requires a specially trained dermatologist and ancillary personnel.
- Multiple injections of local anesthetic can cause patient discomfort.
Limitations of Mohs surgery may include the following:
- Noncontiguous tumors and/or disconnected foci in tumors may result in recurrence.
- Adjunctive therapy may be necessary to ensure cure.
- The extent of the tumor may be too great to be amenable to surgery.
Issues to consider and evaluate prior to Mohs surgery include the following:
- Patient’s general health, history (including medications, allergies, previous surgeries/hospitalization, potential complicating conditions such as diabetes, cardiovascular/pulmonary compromise, history of prolonged bleeding, or tendency for keloid/scar formation)
- Review of the skin tumor’s gross appearance and histologic features
- Discussion with patient regarding Mohs surgery technique, alternative therapeutic options, potential complications from the procedure, and postprocedure wound care and reconstructive options
- Discussion with patient about cessation of alcohol and/or tobacco use during the perioperative period
- Discussion with patient about food, medications, and attire on the day of surgery, as well as postoperative issues
- Interdisciplinary consultations (eg, dermatology, pathology, cutaneous/oncologic surgery, reconstructive surgery)
Mohs fresh-frozen technique: general, basic procedure
See the list below:
- Outline the tumor; then administer local anesthesia.
- Debulk the tumor with a curette to delineate the tumor extent (Note: This is less effective with morpheaform BCCs or other nonfriable tumors).
- Tattoo or mark the tumor for precise orientation of the tissue specimen.
- Excise the tissue (a) with the scalpel angled 45° to the skin (to bevel the edge to facilitate histologic processing); (b) circumferentially around the tumor at a 45° angle; and (c) under the skin, parallel to the surface, so that the deep margin is excised horizontally.
- Achieve hemostasis with spot electrodesiccation, suture ligatures, oxidized cellulose (eg, Surgicel, Oxycel), pressure, or other methods.
- Draw a 2-dimensional (2-D) map of the patient's skin defect; include the tattoos/marks that were used to orient the specimen.
- Divide the tissue along the tattooed or scored lines, and invert the tissue (dermis turned up); then, color code the edges of the specimen with tissue dyes.
- Mount the tissue, flattening the undersurface in an even horizontal plane; use a cryostat to cut 5- to 7-µm horizontal frozen sections of each tissue specimen; and place the specimens on slides.
- Stain the slides (usually with hematoxylin-eosin or toluidine blue), and interpret the results.
- Mark any residual neoplasm in red on the 2-D map of the patient’s skin defects; remove the additional tissue where residual tumor has been identified.
- Immediately reconstruct the resulting postprocedure defect.
Mohs fixed-tissue technique (infrequently used)
See the list below:
- Debulk the tumor with a curette, and apply dichloroacetic acid.
- Apply a layer of zinc chloride paste (fixative paste).
- Cover the fixative paste with an occlusive dressing for 6-24 hours.
- After tissue fixation, perform the fixed-tissue surgical technique similarly to the fresh-tissue technique (ie, with the scalpel angled 45° to the skin, make an incision in the fixed tissue near the border of the unfixed tissue, and continue in the fixed tissue parallel to the skin surface); then, examine the tissue sections under microscopy, and apply additional fixative paste to any remaining areas of tumor involvement for another 6-24 hours.
- Excise any residual tumor in the same manner as the fresh-tissue technique, generally at a rate of one stage of excision per day.
- After achieving a tumor-free defect, allow the remaining fixed tissue to slough (the process generally takes a few days).
- Repair the defect or allow it to heal by means of secondary intention.
See the list below:
- Nerve damage
Introduction, history, and training
Mohs micrographic surgery (MMS), or Mohs surgery, is a surgical technique used to treat various skin cancers that allows precise microscopic control of the margins by utilizing tangentially cut frozen-section histology. In this procedure, cutaneous tumors are excised at a 45° angle with mapping, and light microscopy is used for subsequent identification of residual cancer. This method provides total histologic control of the surgical margins, and it achieves the lowest recurrence rate with maximal preservation of uninvolved tissue. Mohs surgery has become the treatment of choice for most skin cancers on the head and neck as well as for recurrent or histologically aggressive lesions.
History and nomenclature
As a medical student at the University of Wisconsin, Frederic E. Mohs initially developed his eponymous technique, at the time referred to as chemosurgery, by using a zinc chloride paste to fix tissue in vivo prior to surgical procedures. This chemosurgery fixed-tissue technique offered remarkably high cure rates, but it also had some drawbacks, including the following:
- The application of zinc chloride paste on the skin cancer was uncomfortable for the patient.
- Only one stage of Mohs surgery could usually be performed each day.
- Zinc chloride paste caused tissue necrosis; therefore, immediate reconstruction was not possible until sloughing of any remaining fixed tissue was completed.
In 1953, during filming of the fixed-tissue technique for a basal cell carcinoma (BCC) of the eyelid, Mohs performed the last few layers without the zinc chloride fixative to speed up the process. The tangential frozen sections he obtained worked so well that Mohs continued this fresh-tissue technique for all eyelid carcinomas. In 1969, he reported a 5-year cure rate of 100% using the fresh-tissue technique to excise eyelid carcinomas. Wide acceptance of the fresh-tissue technique increased substantially after the publication of Tromovitch and Stegman's series in 1974 and Mohs' series in 1976.
Advantages of the fresh-tissue technique compared with the fixed-tissue technique of Mohs surgery include the following:
- Avoidance of the pain caused by tissue fixation on the skin
- Ability to perform multiple stages in one day
- Ability to repair the defect immediately after tumor-free margins are achieved
The use of “chemo” in the name for the original technique was confusing to patients and physicians; as a result, the terms Mohs surgery and Mohs micrographic surgery came into existence. Currently, Mohs surgery, fresh-tissue technique, is the official name for this procedure, because the fixed-tissue technique is rarely used. The acronym MOHS, micrographically oriented histographic surgery, has also been proposed, but it has not achieved widespread recognition.
Changes in nomenclature have also occurred in the Mohs College as the terminology has evolved. The first annual meeting of the American College of Chemosurgery occurred in 1967. In 1986, the American College of Chemosurgery changed its name to the American College of Mohs Micrographic Surgery, because most surgeons were using the fresh-tissue technique rather than the fixed-tissue technique. To more accurately reflect the clinical practices of its members, its name was changed again in 1987 to the American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO). The current official name of the Mohs College has been condensed to the American College of Mohs Surgery (ACMS).
Before the 1980s, training in Mohs surgery was informal and without criteria. Currently, to become a member of ACMS, a physician must have successfully completed a 1- to 2-year postresidency fellowship that is invaluable in equipping trainees with competency in Mohs surgery, reconstructive surgery, and dermatopathology skills. Mohs Surgery fellowships have transitioned into American Council of Graduate Medical Education (ACGME) accredited fellowships, known as Procedural Dermatology, because these fellowships train fellows to perform other techniques in addition to Mohs surgery.
Reeder VJ, Gustafson CJ, Mireku K, Davis SA, Feldman SR, Pearce DJ. Trends in Mohs surgery from 1995 to 2010: an analysis of nationally representative data. Dermatol Surg. 2015 Mar. 41 (3):397-403. [Medline].
Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 Oct. 67(4):531-50. [Medline].
Jeon SY, Kim KH, Song KH. Efficacy of photodynamic diagnosis-guided Mohs micrographic surgery in primary squamous cell carcinoma. Dermatol Surg. 2013 Dec. 39(12):1774-83. [Medline].
Chin-Lenn L, Murynka T, McKinnon JG, Arlette JP. Comparison of outcomes for malignant melanoma of the face treated using mohs micrographic surgery and wide local excision. Dermatol Surg. 2013 Nov. 39(11):1637-45. [Medline].
Rowe DE, Carroll RJ, Day CL Jr. Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection. J Am Acad Dermatol. 1992 Jun. 26(6):976-90. [Medline].
Padilla RS, Bailin PL, Howard WR, Dinner MI. Verrucous carcinoma of the skin and its management by Mohs' surgery. Plast Reconstr Surg. 1984 Mar. 73(3):442-7. [Medline].
Swanson NA, Taylor WB. Plantar verrucous carcinoma. Literature review and treatment by the Mohs' chemosurgery technique. Arch Dermatol. 1980 Jul. 116(7):794-7. [Medline].
Cheville JC, Bromley C, Argenyi ZB. Trisomy 7 in keratoacanthoma and squamous cell carcinoma detected by fluorescence in-situ hybridization. J Cutan Pathol. 1995 Dec. 22(6):546-50. [Medline].
Goldenhersh MA, Olsen TG. Invasive squamous cell carcinoma initially diagnosed as a giant keratoacanthoma. J Am Acad Dermatol. 1984 Feb. 10(2 Pt 2):372-8. [Medline].
Hodak E, Jones RE, Ackerman AB. Solitary keratoacanthoma is a squamous-cell carcinoma: three examples with metastases. Am J Dermatopathol. 1993 Aug. 15(4):332-42; discussion 343-52. [Medline].
Kingman J, Callen JP. Keratoacanthoma. A clinical study. Arch Dermatol. 1984 Jun. 120(6):736-40. [Medline].
Mikhail GR. Squamous cell carcinoma diagnosed as keratoacanthoma. Cutis. 1974. 13:378-84.
Schwartz RA. Keratoacanthoma. J Am Acad Dermatol. 1994 Jan. 30(1):1-19; quiz 20-2. [Medline].
Archer CB, Louback JB, MacDonald DM. Spontaneous regression of perianal extramammary Paget's disease after partial surgical excision. Arch Dermatol. 1987 Mar. 123(3):379-82. [Medline].
Chanda JJ. Extramammary Paget's disease: prognosis and relationship to internal malignancy. J Am Acad Dermatol. 1985 Dec. 13(6):1009-14. [Medline].
Coldiron BM, Goldsmith BA, Robinson JK. Surgical treatment of extramammary Paget's disease. A report of six cases and a reexamination of Mohs micrographic surgery compared with conventional surgical excision. Cancer. 1991 Feb 15. 67(4):933-8. [Medline].
Hurt MA, Hardarson S, Stadecker MJ, Santa Cruz DJ. Fibroepithelioma-like changes associated with anogenital epidermotropic mucinous carcinoma. Fibroepitheliomatous Paget phenomenon. J Cutan Pathol. 1992 Apr. 19(2):134-41. [Medline].
Jones RE Jr, Austin C, Ackerman AB. Extramammary Paget's disease. A critical reexamination. Am J Dermatopathol. 1979 Summer. 1(2):101-32. [Medline].
Mazoujian G, Pinkus GS, Haagensen DE Jr. Extramammary Paget's disease--evidence for an apocrine origin. An immunoperoxidase study of gross cystic disease fluid protein-15, carcinoembryonic antigen, and keratin proteins. Am J Surg Pathol. 1984 Jan. 8(1):43-50. [Medline].
Misago N, Toda S, Hikichi Y, Iyadomi M, Kohda H. A unique case of extramammary Paget's disease. Derivation from eccrine porocarcinoma?. Am J Dermatopathol. 1992 Dec. 14(6):553-9. [Medline].
Piura B, Zirkin HJ. Vulvar Paget's disease with an underlying sweat gland adenocarcinoma. J Dermatol Surg Oncol. 1988 May. 14(5):533-7. [Medline].
Burns MK, Chen SP, Goldberg LH. Microcystic adnexal carcinoma. Ten cases treated by Mohs micrographic surgery. J Dermatol Surg Oncol. 1994 Jul. 20(7):429-34. [Medline].
Chiller K, Passaro D, Scheuller M, Singer M, McCalmont T, Grekin RC. Microcystic adnexal carcinoma: forty-eight cases, their treatment, and their outcome. Arch Dermatol. 2000 Nov. 136(11):1355-9. [Medline].
Cooper PH. Sclerosing carcinomas of sweat ducts (microcystic adnexal carcinoma). Arch Dermatol. 1986 Mar. 122(3):261-4. [Medline].
Friedman PM, Friedman RH, Jiang SB, Nouri K, Amonette R, Robins P. Microcystic adnexal carcinoma: collaborative series review and update. J Am Acad Dermatol. 1999 Aug. 41(2 Pt 1):225-31. [Medline].
Goldstein DJ, Barr RJ, Santa Cruz DJ. Microcystic adnexal carcinoma: a distinct clinicopathologic entity. Cancer. 1982 Aug 1. 50(3):566-72. [Medline].
Wallace RD, Bernstein PE. Microcystic adnexal carcinoma. Ear Nose Throat J. 1991 Nov. 70(11):789-93. [Medline].
ADAMS JT, SALTZSTEIN SL. METASTASIZING DERMATOFIBROSARCOMA PROTUBERANS: REPORT OF TWO CASES. Am Surg. 1963 Dec. 29:878-86. [Medline].
Barnes L, Coleman JA Jr, Johnson JT. Dermatofibrosarcoma protuberans of the head and neck. Arch Otolaryngol. 1984 Jun. 110(6):398-404. [Medline].
Bendix-Hansen K, Myhre-Jensen O, Kaae S. Dermatofibrosarcoma protuberans. A clinico-pathological study of nineteen cases and review of world literature. Scand J Plast Reconstr Surg. 1983. 17(3):247-52. [Medline].
Bonnabeau RC Jr, Stoughton WB, Armanious AW, Cuono CB, Mossburg WL, Lancaster JR. Dermatofibrosarcoma protuberans. Report of a case with pulmonary metastasis and multiple intrathoracic recurrences. Oncology. 1974. 29(1):1-12. [Medline].
Garcia C, Clark RE, Buchanan M. Dermatofibrosarcoma protuberans. Int J Dermatol. 1996 Dec. 35(12):867-71. [Medline].
Gloster HM Jr, Harris KR, Roenigk RK. A comparison between Mohs micrographic surgery and wide surgical excision for the treatment of dermatofibrosarcoma protuberans. J Am Acad Dermatol. 1996 Jul. 35(1):82-7. [Medline].
Hess KA, Hanke CW, Estes NC, Shideler SJ. Chemosurgical reports: myxoid dermatofibrosarcoma protuberans. J Dermatol Surg Oncol. 1985 Mar. 11(3):268-71. [Medline].
Jimenez FJ, Grichnik JM, Buchanan MD, Clark RE. Immunohistochemical margin control applied to Mohs micrographic surgical excision of dermatofibrosarcoma protuberans. J Dermatol Surg Oncol. 1994 Oct. 20(10):687-9. [Medline].
Kahn LB, Saxe N, Gordon W. Dermatofibrosarcoma protuberans with lymph node and pulmonary metastases. Arch Dermatol. 1978 Apr. 114(4):599-601. [Medline].
Mikhail GR, Lynn BH. Dermatofibrosarcoma protuberans. J Dermatol Surg Oncol. 1978 Jan. 4(1):81-4. [Medline].
Peters CW, Hanke CW, Pasarell HA, Bennett JE. Chemosurgical reports. Dermatofibrosarcoma protuberans of the face. J Dermatol Surg Oncol. 1982 Oct. 8(10):823-6. [Medline].
Ratner D, Thomas CO, Johnson TM, Sondak VK, Hamilton TA, Nelson BR, et al. Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread. J Am Acad Dermatol. 1997 Oct. 37(4):600-13. [Medline].
Robinson JK. Dermatofibrosarcoma protuberans resected by Mohs' surgery (chemosurgery). A 5-year prospective study. J Am Acad Dermatol. 1985 Jun. 12(6):1093-8. [Medline].
Sagi A, Ben-Yakar Y, Mahler D. A ten-year-old boy with dermatofibrosarcoma protuberans of the face. J Dermatol Surg Oncol. 1987 Jan. 13(1):82-3. [Medline].
Altman DA, Nickoloff BJ, Fivenson DP. Differential expression of factor XIIIa and CD34 in cutaneous mesenchymal tumors. J Cutan Pathol. 1993 Apr. 20(2):154-8. [Medline].
Kutzner H. Expression of the human progenitor cell antigen CD34 (HPCA-1) distinguishes dermatofibrosarcoma protuberans from fibrous histiocytoma in formalin-fixed, paraffin-embedded tissue. J Am Acad Dermatol. 1993 Apr. 28(4):613-7. [Medline].
Dzubow LM. Sebaceous carcinoma of the eyelid: treatment with Mohs surgery. J Dermatol Surg Oncol. 1985 Jan. 11(1):40-4. [Medline].
Nelson BR, Hamlet KR, Gillard M, Railan D, Johnson TM. Sebaceous carcinoma. J Am Acad Dermatol. 1995 Jul. 33(1):1-15; quiz 16-8. [Medline].
Yount AB, Bylund D, Pratt SG, Greenway HT. Mohs micrographic excision of sebaceous carcinoma of the eyelids. J Dermatol Surg Oncol. 1994 Aug. 20(8):523-9. [Medline].
Zalla MJ, Randle HW, Brodland DG, Davis JL, Roenigk RK. Mohs surgery vs wide excision for atypical fibroxanthoma: follow-up. Dermatol Surg. 1997 Dec. 23(12):1223-4. [Medline].
Kimyai-Asadi A, Ayala GB, Goldberg LH, Vujevich J, Jih MH. The 20-minute rapid MART-1 immunostain for malignant melanoma frozen sections. Dermatol Surg. 2008 Apr. 34(4):498-500. [Medline].
Albertini JG, Elston DM, Libow LF, Smith SB, Farley MF. Mohs micrographic surgery for melanoma: a case series, a comparative study of immunostains, an informative case report, and a unique mapping technique. Dermatol Surg. 2002 Aug. 28(8):656-65. [Medline].
Snow SN, Mohs FE, Oriba HA, Dudley CM, Leverson G, Hetzer M. Cutaneous malignant melanoma treated by Mohs surgery. Review of the treatment results of 179 cases from the Mohs Melanoma Registry. Dermatol Surg. 1997 Nov. 23(11):1055-60. [Medline].
Chesser RS, Bertler DE, Fitzpatrick JE, Mellette JR. Primary cutaneous adenoid cystic carcinoma treated with Mohs micrographic surgery toluidine blue technique. J Dermatol Surg Oncol. 1992 Mar. 18(3):175-6. [Medline].
Bullen R, Larson PO, Landeck AE, Nychay S, Snow SN, Hazen P, et al. Angiosarcoma of the head and neck managed by a combination of multiple biopsies to determine tumor margin and radiation therapy. Report of three cases and review of the literature. Dermatol Surg. 1998 Oct. 24(10):1105-10. [Medline].
Afshar M, Lee RA, Jiang SI. Desmoplastic trichilemmoma--a report of successful treatment with Mohs micrographic surgery and a review and update of the literature. Dermatol Surg. 2012 Nov. 38(11):1867-71. [Medline].
Van Mierlo PL, Geelen GM, Neumann HA. Mohs micrographic surgery for an erosive adenomatosis of the nipple. Dermatol Surg. 1998 Jun. 24(6):681-3. [Medline].
Bernstein SC, Roenigk RK. Leiomyosarcoma of the skin. Treatment of 34 cases. Dermatol Surg. 1996 Jul. 22(7):631-5. [Medline].
Davidson LL, Frost ML, Hanke CW, Epinette WW. Primary leiomyosarcoma of the skin. Case report and review of the literature. J Am Acad Dermatol. 1989 Nov. 21(5 Pt 2):1156-60. [Medline].
Iacobucci JJ, Stevenson TR, Swanson NA, Headington JT. Cutaneous leiomyosarcoma. Ann Plast Surg. 1987 Dec. 19(6):552-4. [Medline].
Brown MD, Swanson NA. Treatment of malignant fibrous histiocytoma and atypical fibrous xanthomas with micrographic surgery. J Dermatol Surg Oncol. 1989 Dec. 15(12):1287-92. [Medline].
Weimar VM, Ceilley RI. Chemosurgical reports. A myxoid variant of malignant fibrous histiocytoma: report of a case treated by Moh's technique with a slight modification. J Dermatol Surg Oncol. 1979 Jan. 5(1):16-8. [Medline].
Melancon JM, Tom WL, Lee RA, Jackson M, Jiang SI. Management of pilomatrix carcinoma: a case report of successful treatment with Mohs micrographic surgery and review of the literature. Dermatol Surg. 2011 Dec. 37(12):1798-805. [Medline].
American Heart Association. Infective endocarditis. Available at http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/TheImpactofCongenitalHeartDefects/Infective-Endocarditis_UCM_307108_Article.jsp. Accessed: January 23, 2014.
Wright TI, Baddour LM, Berbari EF, Roenigk RK, Phillips PK, Jacobs MA, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008 Sep. 59(3):464-73. [Medline].
Matzke TJ, Christenson LJ, Christenson SD, Atanashova N, Otley CC. Pacemakers and implantable cardiac defibrillators in dermatologic surgery. Dermatol Surg. 2006 Sep. 32(9):1155-62; discussion 1162. [Medline].
El-Gamal HM, Dufresne RG, Saddler K. Electrosurgery, pacemakers and ICDs: a survey of precautions and complications experienced by cutaneous surgeons. Dermatol Surg. 2001 Apr. 27(4):385-90. [Medline].
Burg G, Hirsch RD, Konz B, Braun-Falco O. Histographic surgery: accuracy of visual assessment of the margins of basal-cell epithelioma. J Dermatol Surg. 1975 Oct. 1(3):21-4. [Medline].
Oganesyan G, Jarell AD, Srivastava M, Jiang SI. Efficacy and complication rates of full-thickness skin graft repair of lower extremity wounds after Mohs micrographic surgery. Dermatol Surg. 2013 Sep. 39(9):1334-9. [Medline].
Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. The safety of Mohs surgery: a prospective multicenter cohort study. J Am Acad Dermatol. 2012 Dec. 67(6):1302-9. [Medline].
Alam M, Ibrahim O, Nodzenski M, Strasswimmer JM, Jiang SI, Cohen JL, et al. Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. 2013 Dec. 149(12):1378-85. [Medline].
Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, Fu P, Maloney ME. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol. 2011 Sep. 65(3):576-83. [Medline].
Nasseri E. Prospective Study of Wound Infections in Mohs Micrographic Surgery Using a Single Set of Instruments. Dermatol Surg. 2015 Sep. 41 (9):1008-12. [Medline].
|Feature of Tumor||Mohs Surgery||Excision, Electrodesiccation and Curettage, Cryosurgery, and Radiation Therapy|
|Primary or recurrent||Recurrent or incompletely excised||Primary|
|Location||High risk; on ear, digits, genitalia, or central part of face||Low risk; on trunk and extremities|
|Histologic finding||Aggressive growth pattern: morpheaform, infiltrating, keratotic, perineural or perivascular invasion||Nodular, superficial|
|Size||>0.6-1 cm on face, >2 cm elsewhere||< 0.6-1 cm on face, < 2 cm elsewhere|
|Clinical nature||Ill-defined borders, multicentric, radiation, genetic syndrome with multiple tumors||Well-defined borders|
|Treatment||Primary Tumor, %||Recurrent Tumor, %|
|Electrodesiccation and curettage||7.7||40.0|
|* Less than 5 years; no statistics for 5-year follow-up.|