The Current State of Mohs Surgery for the Treatment of

Melanoma: A Nationwide Cross-Sectional Survey of

Mohs Surgeons
Spyros M. Siscos, MD, Brett C. Neill, MD, Edward W. Seger, MD, MS, Tyler A. Hooton, BS,
and Thomas L. H. Hocker, MD*

BACKGROUND The increased use of Mohs micrographic surgery (MMS) to treat melanoma has been
accompanied by wide variations in practice patterns and a lack of best practice guidelines.

OBJECTIVE The present study was a nationwide cross-sectional survey of Mohs surgeons to elucidate
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commonalities and variations in their use of MMS to treat melanoma.

MATERIALS AND METHODS A cross-sectional analysis was performed using survey responses of Mohs
surgeons with membership in the American College of Mohs Surgery.

RESULTS A total of 210/513 (40.9%) participants used MMS to treat melanoma of any subtype and 123/210
(58.6%) participants within this group treated invasive T1 melanoma (AJCC Eighth Edition) with MMS. A total
of 172/210 (81.9%) participants debulked melanoma in situ (MIS). Average margin size of the first Mohs stage
for MIS was 4.96 6 1.74 mm. A total of 149/210 (71.0%) participants used immunohistochemical stains, with
145/149 (97.3%) using melanoma antigen recognized by T-cells 1 (MART-1) in 96.5% of melanoma cases treated
with MMS.

CONCLUSION Over half of surveyed Mohs surgeons treating melanoma with MMS are treating early inva-
sive melanoma with MMS. Most Mohs surgeons treating melanoma with MMS debulk MIS and virtually all use
MART-1 when excising invasive melanoma with MMS.

The authors have indicated no significant interest with commercial supporters. IRB Approval Status: Reviewed
and approved by KUMC IRB and ACMS Executive Committee.

elanoma is the fifth most common malignant

M neoplasm in the United States, with 100,350
new cases estimated to be diagnosed in 2020.1 Mohs
micrographic surgery (MMS) is emerging as 1 of the
most effective treatment modalities for melanoma
in situ (MIS) and invasive melanoma, with recent
studies demonstrating lower recurrence rates and
improved/noninferior survival outcomes compared
with wide local excision (WLE).2–5 Since 2001, the use
of MMS for melanoma has more than tripled within
the United States.6 However, this increase has been
accompanied by wide variations in practice patterns
across the United States without the development of
best practice guidelines.6 Lack of consensus on the
MMS approach to treating melanoma may be due, in
part, to differences in the fellowship training of Mohs
surgeons, ongoing debates in the literature, concerns
with interpreting frozen sections of melanoma, newer
rapid immunohistochemical (IHC) staining protocols,
and surgeon preference. Given its increased use for
melanoma combined with the lack of best practice
guidelines, this nationwide cross-sectional survey of
Mohs surgeons sought to investigate commonalities
and variations in the use of MMS to treat melanoma.

*All authors are affiliated with the Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided
in the HTML and PDF versions of this article on the journal’s Web site (www.dermatologicsurgery.org).

© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2020;46:1267–1271 DOI: 10.1097/DSS.0000000000002645

1267

© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 THE CURRENT STATE OF MOHS SURGERY

Methods without fellowship exposure (p < .001). Among the

participants with fellowship exposure who treated mel-
This study was a cross-sectional survey of Mohs sur-
anoma with MMS in current practice, 56.9%
geons with membership in the American College of
reported $35 cases and 43.1% reported 1 to 34 cases of
Mohs Surgery (ACMS). An anonymous 35-item
melanoma treated with MMS during fellowship. Par-
multiple-choice survey was developed using REDCap
ticipants who currently treated melanoma with MMS
(Vanderbilt University, TN) and distributed to all
were more likely to have received fellowship training on
ACMS members during October 2019 through
melanocytic IHC stains (61.1% with IHC fellowship
December 2019 using ACMS mailing lists. Mohs
training vs 34.0% without IHC fellowship training,
micrographic surgery was defined as Mohs surgery
p < .001). Male participants treating melanoma with
with intraoperative frozen section analysis. Excisional
MMS were older (age 49.0 [male] vs age 41.5 [female],
surgery with en face permanent section analysis (“slow
p < .001) and had more time in practice (15.2 years
Mohs”) was not considered as MMS for the purposes
[male] vs 9.87 years [female], p = .003). Age and time in
of this study. Fellowship exposure in MMS for mela-
practice did not vary significantly among same-sex par-
noma was defined as the completion of $1 melanoma
ticipants treating versus not treating melanoma with
case treated with MMS during fellowship. Participants
MMS. Among all participants, no significant differences
currently treating melanoma with MMS were queried
were found between sexual identity (male vs female) and
on melanoma subtypes treated (primary tumor [T],
fellowship exposure in MMS for melanoma, number of
AJCC Eighth Edition), anatomic locations treated,
melanoma cases treated with MMS during fellowship, or
initial margin size (the total distance beyond the clin-
fellowship training in melanocytic IHC staining.
ically apparent tumor after excision of the first MMS
stage), processing of debulked melanoma specimens,
Melanoma Types Treated
and IHC staining. The study was approved by the
ACMS executive committee and the institutional Among the 210 participants treating melanoma with
review board of the University of Kansas. Data anal- MMS, the vast majority treated both lentigo maligna
ysis was conducted using SAS, version 9.4 (SAS Insti- (97.5%) and other melanoma in situ subtypes (91.4%).
tute, Inc.). Chi square, Fisher exact test, and t-tests A slight majority (n = 123, 58.6%) reported treating
were used to compare differences between groups, invasive T1 melanoma, and 43 participants (20.5%)
with p < .05 considered statistically significant. reported treating invasive T2 and/or higher stage mela-
noma with MMS (See Supplemental Digital Content 2,
Results Table S2, http://links.lww.com/DSS/A452). Invasive T2
and/or higher stage melanoma was treated by a greater
Demographic Comparisons percentage of participants in academic hospitals com-
pared with other practice settings (30.2% vs 18.1%,
A total of 513 participants completed the survey (average
p = .041). Participants in a nonacademic hospital setting
age 45 6 11 years; 320 [62.4%] men; 365 [71.2%] in
were more likely to treat melanoma in situ (MIS) on the
private practice) (See Supplemental Digital Content 1,
trunk and extremities (excluding the hands and feet) than
Table S1, http://links.lww.com/DSS/A451). Among all
participants in academic hospitals (p = .01) (See Sup-
participants, 210 (40.9%) reported using MMS to treat
plemental Digital Content 2, Table S2, http://links.lww.
melanoma of any subtype. Participants who were older
com/DSS/A452). The number of yearly MIS cases trea-
(age 46.9 vs age 44.1, p < .001), had more time in practice
ted with MMS did not vary significantly between prac-
(13.9 years vs 10.9 years, p < .001), and men (49.4%
tice settings.
men vs 26.9% women, p < .001) were more likely to treat
melanoma with MMS. Over half of all participants (n =
Surgical/Processing Techniques
266, 51.9%) received fellowship exposure in MMS for
melanoma. Most (57.5%) participants with fellowship When treating MIS with MMS, 172 participants
exposure treated melanoma with MMS in current (81.9%) reported initially excising the clinically visible
practice, in contrast with only 23.1% of participants tumor (debulking) before excising the initial Mohs

1268 DERMATOLOGIC SURGERY

© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

stage, with virtually all (171/172 [99.4%]) sharply
debulking MIS with a scalpel (See Supplemental
Digital Content 3, Table S3, http://links.lww.
com/DSS/A453). Over half (100/171 [58.5%]) of
surgeons who sharply debulk MIS submit the entire
debulked specimen for permanent vertical (bread-loaf)
sectioning. A minority (18/171 [10.5%]) submit the
entire debulked specimen for frozen vertical section-
ing, and 49/171 (28.7%) submit portions of the
debulked specimen for both permanent and frozen
vertical sectioning. When treating MIS with MMS, the
average initial margin size (debulk margin if applica-
ble + initial Mohs stage margin i.e. total distance
beyond the clinically apparent tumor) was 4.96 6
1.74 mm. The average initial margin size did not vary
significantly between practice settings nor among
participants using versus not using IHC stains.
Immunohistochemical Staining
More than half (149/210 [71%]) of participants treating
melanoma with MMS reported using melanocytic IHC
stains (See Supplemental Digital Content 3, Table S3,
http://links.lww.com/DSS/A453). Participants using IHC
stains were younger (age 45 vs age 52, p < .01) and
reported less time in practice (12.3 years vs 18.0 years,
p < .01). Virtually all (145/149 [97.3%]) participants
using melanocytic IHC stains reported using melanoma
antigen recognized by T-cells 1 (MART-1) as their pri-
mary IHC stain. Regarding frequency of use, participants
who use IHC stains used MART-1 in 96.5% of their
melanoma cases treated with MMS (See Supplemental
Digital Content 3, Table S3, http://links.lww.
com/DSS/A453). A greater percentage (78.9%) of par-
ticipants treating invasive melanoma used MART-1
compared with the 51.9% of participants exclusively
treating noninvasive melanoma (p < .001). Participants in
private practice were more likely to use hand staining
versus automated staining compared with participants in
academic hospitals (81.7% vs 53.5%, p < .001). Tradi-
tional IHC staining protocols (53.2%) and rapid IHC
staining protocols (51.4%) were used at a similar rate.
Discussion
In this nationwide cross-sectional survey, less than half
of surveyed Mohs surgeons reported treating
© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
SISCOS ET AL
melanoma with MMS. The percentage (40.9%) of
Mohs surgeons treating melanoma with MMS was
similar compared with a study conducted in 2012
(38.5%).7 However, ACMS membership has increased
from 1,095 members in 2012 to 1,630 members in
2019, suggesting an overall increase in the number of
Mohs surgeons treating melanoma with MMS. In
addition, with its increased use for treatment of mela-
noma, Mohs surgeons who previously treated MIS with
MMS may be increasingly doing so and/or expanding
their scope of treatment to include invasive melanoma.
The present study highlights the importance of fellow-
ship exposure to MMS and IHC staining for mela-
noma. In addition, the creation of postfellowship
training opportunities in MMS and IHC staining for
melanoma may help broaden its use among Mohs
surgeons who received inadequate fellowship exposure.
In this study, male Mohs surgeons were more likely to
use MMS to treat melanoma compared with female
Mohs surgeons. Although this finding may be due to a
variety of factors, our data demonstrated similar fel-
lowship exposure to MMS for melanoma and IHC
stains among male and female Mohs surgeons. Male
Mohs surgeons were older and had more time in
practice, although it is unclear how these factors may
influence the use of MMS for melanoma.
The American Academy of Dermatology/American
College of Mohs Surgery/American Society for Der-
matologic Surgery Association/American Society for
Mohs Surgery Ad Hoc Task Force on Appropriate Use
Criteria for Mohs surgery8 does not currently offer
specific recommendations on the use of MMS for
invasive melanoma. In this study, over half (58.6%) of
Mohs surgeons treating melanoma with MMS treated
invasive melanoma. This finding may be due, in part,
to upstaging during the MMS procedure and the
increasing evidence demonstrating improved survival
of early-invasive melanoma treated with MMS com-
pared with WLE.2,4 In addition, the advent of mela-
nocytic IHC stains, particularly MART-1, has
improved the accuracy of interpreting frozen sections
of melanoma, with MART-1 providing equivalent
information on frozen sections of melanoma com-
pared with that obtained in MART-1 permanent sec-
tions.9–13 Furthermore, recent studies have
demonstrated that MMS aided by MART-1 achieves
46:10:OCTOBER 2020 1269
 THE CURRENT STATE OF MOHS SURGERY
low local recurrence rates for MIS and invasive mel-
anoma compared with published recurrence rates
achieved with WLE.5,14 In this study, most Mohs
surgeons reported using IHC stains (almost exclu-
sively MART-1), with MART-1 being used by a
greater percentage of Mohs surgeons treating invasive
melanoma with MMS compared with Mohs surgeons
exclusively treating noninvasive melanoma with
MMS. Despite growing evidence supporting the use of
IHC stains with MMS for melanoma, 29% of sur-
veyed Mohs surgeons treating melanoma with MMS
are not using IHC stains. Mohs micrographic surgery
without IHC has been associated with as high as a
33% recurrence rate.15 This may be due, in part, to the
difficulty visualizing atypical melanocytes on frozen
sections, particularly on sun-damaged skin, where
prominent single melanocytes may reside in the
absence of disease.15 Concerns regarding the wide-
spread use of MMS for melanoma are legitimate when
important variations in practice patterns exist.6
Recent studies have demonstrated a higher likeli-
hood of melanoma being treated with MMS at
academic centers.2,4 Although the reasons behind
this finding are unclear,2,4 our analysis found no
association between a Mohs surgeon’s practice set-
ting and treating noninvasive melanoma with MMS.
In addition, Mohs surgeons working in academic
hospitals did not report a significantly higher annual
number of MIS cases treated with MMS compared
with Mohs surgeons working in other practice set-
tings. However, Mohs surgeons working in aca-
demic hospitals were more likely to treat invasive T2
and/or higher stage melanoma with MMS, a factor
which likely broadens the spectrum of melanoma
subtypes treated with MMS at academic institu-
tions. These findings suggest that academic institu-
tions may be treating a greater percentage of
invasive melanomas with MMS.
A recent study suggested that if comprehensive margin
assessment surgery (e.g. MMS) is not used, initial
surgical margins of at least 10-mm for primary
trunk/extremity and 12-mm for head/neck melanomas
should be used to achieve histologically negative
margins 97% of the time.16 These initial margins may
not always be desirable or feasible, particularly when
1270 DERMATOLOGIC SURGERY
© 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
aiming to preserve cosmesis and function. In this
regard, MMS fills a gap in the treatment of melanoma.
On average, Mohs surgeons in the present study repor-
ted using initial margins for MIS treated with MMS that
are at the lower end of the 0.5 to 1.0 cm range for WLE
recommended by the National Comprehensive Cancer
Network and American Academy of Dermatology.17,18
In this study, most Mohs surgeons reported submitting a
debulked MIS specimen for breadloafing to evaluate for
deeper tumor invasion. Although we did not assess for
margins used when debulking MIS, debulking the visible
tumor with a peripheral margin of at least 2 to 3 mm of
clinically normal-appearing skin has previously been
advocated.14 Breadloafing the debulked specimen allows
for accurate measurement of Breslow depth.19 In
addition, breadloafing the debulked specimen with fro-
zen sections allows for timely detection of upstaging to
facilitate sentinel lymph node biopsy, if applicable,
before tissue rearrangement and disruption of lymphatic
drainage from reconstruction.14 Breadloafing addition-
ally provides a positive control and enables precise
evaluation of the relationship between the clinical and
pathologic surgical margins.14 The information obtained
from breadloafing debulked specimens of melanoma
may be useful when interpreting a Mohs layer with
heavily sun-damaged skin. It is unclear why a minority of
surveyed Mohs surgeons reported not debulking MIS.
Prior studies have demonstrated a wide range of MIS
lesions on initial biopsy which were subsequently
upstaged to invasive melanoma after histological review
of the entire lesion.20,21 These staging discrepancies
may stem from initial subtotal biopsies which can
misrepresent the depth of both MIS and invasive
melanoma. Histologic evaluation of debulked mela-
noma specimens during MMS is recommended for
optimal staging, treatment, and follow-up.18,22
Limitations and Future Directions
Limitations of this study include the response rate
(513/1,630 [31.5%]), which was similar compared
with a previous survey of the ACMS membership
(378/1,095 [34.5%]).7 In addition, responses may be
biased and overstate the percentage of Mohs surgeons
treating melanoma with MMS. The data in the present

study provide a cross-sectional view exclusively of the
ACMS membership and do not represent all derma-
tologists who may utilize MMS. Anatomic site, num-
ber of cases treated with MMS per year, initial margin
size and debulking characteristics pertain to MIS only.
This study did not investigate margin sizes used when
debulking melanoma. Future research may help better
define and characterize margin size variations during
the first Mohs stage. In addition, this study did not
investigate initial margins for invasive melanoma
treated with MMS or the depth of the initial Mohs
stage. Future studies investigating these important
parameters are warranted and may help to further
guide treatment.
Conclusion
To our knowledge, this study is the largest cross-
sectional survey to date to examine the practice pat-
terns of Mohs surgeons currently treating melanoma
with MMS. These findings update and add to the
limited information previously available regarding the
use of MMS for melanoma in the United States.6,23 As
the use of MMS to treat melanoma increases, we hope
this analysis will help to reduce variations in practice
patterns and ultimately help guide the development of
best practice guidelines.
Acknowledgments The authors thank Jo Wick, PhD
for assisting with the statistical analysis in this study.
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Address correspondence and reprint requests to: Brett
Neill, MD, Division of Dermatology, University of Kansas
Medical Center, 3901 Rainbow Blvd, Kansas City, KS
66160, or e-mail: bcneill6@gmail.com
46:10:OCTOBER 2020 1271