DermWorld

directions in residency A Publication of the American Academy of Dermatology | Association

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Mohs micrographic surgery
By Michael J. Visconti, DO, Emily R. Davis, DO, Brayden J. Healey, DO, and Kent J. Krach, MD, FAAD

Mohs micrographic surgery

Overall process
Michael J.
Visconti, DO, is
a PGY-3 dermatology
resident at St. Joseph
Mercy Ann Arbor.

Emily R. Davis,
DO, is a PGY-5 Mohs
micrographic surgery
fellow at St. Joseph
Mercy Ann Arbor under
the training of Kent J.
Krach, MD, FAAD.

Background
• Method for precise tumor extirpation using circumferential (360°) microscopic margin
control and precision mapping with immediate re-excision of remaining cancer
• Highest evidence-based cure rate for most cutaneous malignancies
• Physician must act as both the surgeon and pathologist
• Relies on the contiguous growth of tumors
- Contiguous growth may be disrupted by prior incisional/excisional treatment
Brayden J. • Advantages
Healey, DO, is a - Tissue-sparing
PGY-4 dermatology - Narrow margins taken because of increased confidence of clearance
resident and the Chief - Microscopic evaluation of ~100% of the margin (vs. 1-2% with traditional bread loaf
processing)
Resident at St. Joseph
- Performed under local anesthesia
Mercy Ann Arbor. - Low complication rates
- MMS has higher cure rates and smaller defects compared to WLE
- High patient satisfaction: 97% of patients willing to undergo future MMS if warranted at
1 month (smoking history and anticoagulation use may negatively affect these scores)

Tumor features Background skin features

Kent J. Krach,
MD, FAAD, is
a board-certified
dermatologist, Indications for
fellowship-trained Mohs
Surgeon (FACMS), and
the program director for
the Micrographic Surgery
and Dermatologic
Oncology (MSDO)
Fellowship at St. Joseph
Mercy Ann Arbor.
• Recurrent tumors • Chronic scar
• Incompletely excised tumors (Marjolin ulcer)
• Tumors located in high-risk anatomic • Within field of prior
locations ionizing radiation
- Area H: Central face, eyelids, eye-
Patient features
brows, nose, lips, chin, ear, periau-
ricular, temple • Immunocompromised:
- Area M: Cheeks, forehead, scalp, solid organ transplant
MMS neck, jawline, pretibial surface (heart is #1 risk), CLL,
- Special sites: Hands, feet, nails, HIV, pharmacologic
genitals • Underlying genetic
• Aggressive histologic subtype syndrome
• Perineural invasion - XP
• Large size (>2 cm) - Gorlin Syndrome
• Poorly defined clinical borders
(lateral and/or deep)
• Rapid growth

p. 1 • Fall 2022 www.aad.org/DIR

boards fodder
Mohs micrographic surgery
By Michael J. Visconti, DO, Emily R. Davis, DO, Brayden J. Healey, DO, and Kent J. Krach, MD, FAAD

Example of MMS surgical tray setup

Essential steps in Mohs micrographic surgery: Case example

Step 1. Step 2. Step 3.

The tumor is debulked (Gillette blade and/or Epidermis is scored The dashed circular red line represents the
curette) to allow for a more precise first stage for orientation. 1-2 chosen 1 mm excisional margins for the first
tissue specimen. The red dot indicates 12 mm margins of stage. A 30-45° beveled excision is
o’clock directionality for ex-vivo mapping. clinically normal skin performed for stage I, removing a bowl-
The tumor in the 11 o’clock position indicates surrounding the shaped tissue specimen for frozen section
sub-clinical spread of tumor (residual tumor). tumor are identified. processing.

Step 4. Step 5. Step 6. Step 7.

The beveled, The specimen may The specimen is flat- The specimen is inverted to
bowl-shaped be bisected for easier tened, allowing for reveal the deep margin at the top
specimen is oriented processing and inked epidermis and deep of the block of tissue.
on the tissue map. on the inner edges to dermis to lay in the
aid with mapping same plane and
orientation. thus 360° margin
evaluation.
p. 2 • Fall 2022 www.aad.org/DIR
boards fodder
Mohs micrographic surgery
By Michael J. Visconti, DO, Emily R. Davis, DO, Brayden J. Healey, DO, and Kent J. Krach, MD, FAAD

Essential steps in Mohs micrographic surgery: Case example

Step 8. Step 9.
The specimen is placed in a mounting medium, Within the mounting medium, the deepest margin sits most
frozen via heat extraction, and prepared for superficially in the tissue block. The microtome is used to slice the
microtome slicing to generate slides. tissue into sections for slide generation.

Step 11.
First stage is
analyzed
microscopically.
Residual tumor is
Step 10. identified within the Step 12. Step 13. Step 14.
Example of how slides epidermal and deep The residual tumor Local anesthesia Although not
are generated with the margins of the is marked on the is repeated. The clinically visible,
“truest margin” closest stage I specimen. surgeon’s map to second stage is after removal of the
to the frost of the slide direct the stage II obtained utilizing the second stage a
in A-1. Further cuts excision. surgeon’s map residual area of
into the block generate generated in tumor remains within
the remainder of speci- step 14. the stage II defect.
mens on the A-1 and
A-2 slides.

Step 15.
Second stage is
analyzed
microscopically.

No residual Step 16. Step 17. Step 18.

tumor is The surgeon’s map is Two stages were The resulting defect after two stages. In
completed with performed, resulting this situation, linear closure is planned.
identified
denotation of in a primary defect Debeveling is performed and Burow’s
microscopically with extension in the triangles are removed along the line of
negative margins. northwest direction. closure to assist with reapproximation.

References:
1. Alikhan A, Hocker TL. Review of Dermatology. Elsevier; 2017.
2. Bolognia J, Jorizzo J, Schaffer I. Dermatology. Philadelphia: Elsevier; 2017.
3. Robinson JK, Hanke CW, Siegal DM, Fratila A. Surgery of the Skin. Philadelphia: Elsevier; 2015.
4. Ad Hoc Task Force, Connolly SM, Baker DR, 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 [published correction appears
in J Am Acad Dermatol. 2015 Apr;72(4):748]. J Am Acad Dermatol. 2012;67(4):531-550. doi:10.1016/j.jaad.2012.06.009.

p. 3 • Fall 2022 www.aad.org/DIR