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Fundamentals of Mohs Surgery
November, 2019

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Basic Mohs Surgery Howard Steinman, M.D.

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Disclosure of Relevant Relationships with
Industry:

None

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SURGEON’S BRAIN
must participate in
One Brain Philosophy ALL
Of Mohs Surgery aspects of
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Mohs surgery
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Mohs Surgeon
tri

3 4
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Surgeon
ot
N

Excision
o

Mohs Surgeon Mohs Surgeon

D

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Technician
(surgeon oversees)
Surgeon or
Assistant

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Draw Map &
Transfer to lab
Tissue &
Slide preparation

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Mohs Surgeon Mohs Surgeon

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or
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Surgeon! Surgeon & Pathologist

Mohs Surgeon Mohs Surgeon

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Slide review Slide review

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Surgeon
ot
N

Correlate Map Findings

Further excision

Surgeon!
o

Mohs Surgeon Mohs Surgeon

D

Marking Map

11 12

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Strategy

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Basic Mohs Surgery Cure contiguous cancers

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with:
Technique
Narrower surgical margins

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Smaller surgical defects
Higher cure rates

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Tactics

Excise & maintain precisely or Essential Requirements

Excise specimens so
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oriented specimens the complete margin
Examine entire contiguous can be put in one plane
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surgical margin
Precisely locate residual
tumor for excision
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15 16
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Essential Requirements Essential Requirements

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Preserve orientation using: Prepare & interpret pathology

slides ensuring:
N

Reference marks
Tissue inks proper staining & quality
Mohs map complete margin representation
o

correct orientation
D

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Essential Requirements Essential Requirements

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Prepare & interpret pathology slides Mark findings on Mohs map

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to identify: -------------------------------
Residual tumor
If necessary:
Significant inflammation

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Dense and perineural Correlate findings to wound
Incomplete margin representation Remove adequate additional
tissue

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Mohs Surgery

Is a multi-step process or You must:

Mohs Surgery
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understand why each step is
necessary
perform each step correctly;
bu

consistently and precisely

be able to problem solve
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Mohs Surgery
ot

An error or omission in any step:

N

May result in tumor being left in

the patient.
o
D

Dermatol Surg 2019;45:514–518

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Pictorial Review of

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Mohs Steps

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Courtesy of Carlos Garcia, M.D.

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or
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Courtesy of Carlos Garcia, M.D. Courtesy of Carlos Garcia, M.D.

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ot
N
o
D

Courtesy of Carlos Garcia, M.D. Courtesy of Carlos Garcia, M.D.

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Mohs Surgery

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Each Step In More

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Detail

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Courtesy of Carlos Garcia, M.D.

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Day of Consultation

Documenting Tumor Location

Biopsy sites often become
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unapparent before Mohs
Day of Surgery
surgery
Patients will NOT always
bu

remember the location

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33 34
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Documenting Tumor Location

ot

Document tumor location with:

Photograph or diagram
N

Measurements from fixed

anatomic landmarks
o
D

35 36

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Measurements from
fixed anatomic landmarks Borders, Margins &
Reference Marks

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Mark tumor borders

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Mark planned surgical
margins

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Place reference marks

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or Revise Tumor Borders
After injecting anesthesia
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After curetting
----------------------------------------
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Before next Mohs stage

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Surgical Margins Reference Marks

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Surgical margins depend Are extensions of imaginary

on:
N

reference lines extending

Tumor type across the wound
Anatomic location Preserve orientation
o

Histologic findings
Personal preference
D

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Reference Marks

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at
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Reference Lines

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Reference Marks

Superficial “nicks” or Staples

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Sutures or staples
Ink marks
bu

Combination of above Sutures

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45 46
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Reference Nicks
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Incise nicks from perilesional

N

skin onto specimen

Superficial on perilesional skin
Deeper on specimen
o

?Wipe blade between nicks

D

47 48

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Mark before

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excising

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specimen

Specimen will

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contract and
may rotate

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or
Marks must be
visible on Reference Nicks
specimen and
wound Designate a 12 o’clock
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reference mark
Vital for preserving
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orientation
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D

12 o’clock mark
ot
N
o
D

53 54

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October 24, 2013 October 24, 2013

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at
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or
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bu
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Reference Marks Are Reference Marks Are

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Essential For: Essential For:

Preserving orientation of: Subdividing large specimens
N

specimen
wound
map
o

slides
D

59 60

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Reference Marks Are

Essential For:

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Correlating findings from slides

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to map to wound

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or
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bu
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ot
N
o
D

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Number of Reference Lines

Determined by: or Number of Reference Lines

Consider using at least two

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Specimen size lines = four marks
Microtome (chuck) size At 12, 3, 6, & 9 o’clock
bu

Microscope slide width

tri

69 70
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Number of Reference Lines Number of Reference Lines

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Some use a single hatch Some use three marks

N

mark for small lesions Avoids double mark

Self orienting
Prevents marking vital areas
o
D

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Number of Reference Lines

One line for each subdivision or

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cut of a large specimen
bu
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ot
N
o
D

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Reference Lines

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Subdivided pieces CANNOT be

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larger than:
your largest microtome chuck

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your microscope slides

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Reference Lines & Chuck Size

or
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ot

Reference Line
N

for each
1.5 - 2 cm
of specimen size
o
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Sukal, SA, et al: Dermatol Surg 2005;31:763–765.

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Reference Line

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for each
1.5 - 2 cm

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of specimen size

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or
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1 2

5 3
bu

4
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Courtesy of Ken Gross, M.D.

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Tumor Biopsy Slide

Presence of Cartilage
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N
o
D

89 90

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Tumor Biopsy

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at
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Frozen Section Biopsy Slide Frozen Section Tumor Biopsy
Helpful if no biopsy slide is Label biopsy tissue & slides
available “V” or “Vert
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Greatly increases diagnostic For vertically oriented tissue
accuracy sectioning
bu
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ot
N
o
D

95 96

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Debulking Debulking

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at
lic
up
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D
or
Debulking
Debulking
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bu
tri

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D

Debulking Debulking
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NOT a Mohs surgery stage

N

NOT usually a biopsy

o
D

101 102

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Debulking Mohs Stage

Curetting the Tumor Site

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Shriner, et al, J Am Acad Dermatol 1998, 39:7-97

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Curetting The Tumor Site
(BCC’s Only)

Advantage:
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Helps define surgical margins better deep & peripheral
Can revise planned excision margin delineation
bu

after curetting
tri

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D
ot

Disadvantage:
N

May tear epidermis margin

May not ↓ # of stages
Creates floaters
o
D

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at
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or
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bu
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Angled Blade Blade Angle & Incision

ot

(Beveled Edge) Incise at ~45° (30° - 60°)

to level of specimen undercutting
N

Too great an angle prevents

specimen flattening
Too acute an angle may
o

transect tumor & more adnexa

D

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Blade Angle & Incision Blade Angle & Incision

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at
lic
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Gross K; Chapter 2. Mohs surgery and Histopathology: Beyond the Fundamentals Gross K; Chapter 2. Mohs surgery and Histopathology: Beyond the Fundamentals

115 116

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or
te
bu

Too great an angle prevents

specimen flattening Too acute an angle may
transect tumor
tri

Gross K; Chapter 2. Mohs surgery and Histopathology: Beyond the Fundamentals

117 118
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D

Scoring excisional
Countertraction
pattern
ot
N
o
D

119 120

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Smart Fingers
Cut Dependent Side First

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at
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or
Smart Fingers Incise Decisively

Incise down to the tissue plain at

which you will undercut the
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specimen
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Dermatol Surg 2008;34:1082–1084

123 124
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D

Then Cut Around Margin

ot

Using body of blade

N
o
D

Stegman, SJ, et. al: Basics of Dermatologic Surgery

Dermatol Surg 2008;34:1082–1084

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Undercutting Undercutting

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At least one tissue layer

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below expected level of
tumor

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From edge to center
At level you will undermine

up
for repair

127 128

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Undercutting Tissue Level
Cheek/Chin In fat
or
te
Nose Below muscle /above
Ear perichon.
Lip Above perichondrium
bu

Scalp Above muscle

Neck Below galea
In fat or above muscle
tri

Snow, S.N. Atlas of Mohs Surgery Wound

Management: Flaps, Grafts and Wound Care

129 130
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D

Anesthesia Clue
ot
N
o
D

131 132

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Undercutting
Undercutting Error
Scalpel v Scissors

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at
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Facial Danger Zones

or
te
bu

Undercut from edges

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toward center
135 136
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D

Slide Review
ot
N
o
D

137 138

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Preliminary Slide Review Preliminary Slide Review

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First ensure complete margin Missing edges or holes are:

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representation Incomplete margin presentation
Ask for recuts

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1
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c b a 2
bu

2
3
f e d
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Slide Review
ot

Take additional Mohs stages

when you find:
N

Tumor
Missing edges or holes (on recuts)
o
D

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1 2 3 4

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or
Slide Review
Take additional Mohs stages
Understanding what each wafer on
te
when you find:
slides represents in relation to the
Tumor surgical specimen
Missing edges or holes (on recuts)
bu

Dense inflammation
Nerve or vessel inflammation
Orientation error
tri

147 148
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D

Each wafer removed is:

Deeper in the specimen
ot

Farther from the surgical margin

Closer to suspected tumor areas
N
o
D

f e d

149 150

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Excising Additional Tissue

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Decide to remove:

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Peripheral tissue
Deep tissue
Both peripheral & deep

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up
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Excising Additional Tissue
Decide to remove:
or
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one or several specimens Reference Marks
bu
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153 154
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D

Reference Marks Are Reference Marks Are

ot

Essential For: Essential For:

Preserving orientation of Subdividing large specimens
specimen, wound, map and
N

slides
o
D

155 156

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Reference Marks Are

Excising Peripheral Tissue
Essential For:

e
Correlating findings from slides

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to map to wound

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or
Excise peripheral
Excising Peripheral Tissue
tissue
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bu
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159 160
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D

Deep Tissue Near

Excise deep tissue
ot

Peripheral Margin
N
o
D

161 162

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Deep Tissue Near

Peripheral Margin

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at
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Excising Additional Stages

Excise closely clustered foci or Excise closely clustered

foci en bloc
te
en bloc
Excise widely spaced foci
bu

separately
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165 166
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D
ot
N
o
D

167 168

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Excise widely spaced foci

separately

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at
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D
Excising Additional Stages

Excise entire wound, if or

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extensive residual tumor is
present
bu
tri

171 172
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D

Excising Additional Stages Specimen Orientation & Transport

ot

Carefully orient multiple Vital to maintain orientation when

moving the specimen(s) to the lab
N

specimens
o
D

173 174

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Reexcision Margins Reexcision Margins

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Cancer clearance takes Use margins you expect will

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precedence over tissue sparing clear the tumor

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or
te
bu
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Reexcision Deep Margins

ot

Fat – superficial
Specimen Orientation &
N

Fat – deep
Fascia
Transport To Lab
Muscle
Periosteum/Perichondrium
o

Bone/Cartilage
D

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Transfer Gauze
Specimen Orientation & Transport 12 o’clock 12 o’clock

e
mark mark
Transfer gauze:

at
Dot orients corner of transfer gauze
Place specimen 12 o’clock mark at dot

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Specimen Orientation & Transport

Orientation Paper: or12 o’clock

Orientation Paper
te
Arrow point orients paper
mark
Place specimen’s 12 o’clock mark at
point
bu
tri

183 184
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D

Specimen Orientation & Transport Petri Dish

ot

Petri dish:
Tape is marker
N

Place specimen’s 12 o’clock mark

facing tape
o
D

185 186

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Specimen Orientation &

Preliminary Tissue Processing
Transport

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Complete Mohs map Process the least number of

at
Transfer specimen and map sections
to lab Advise technician of:

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fat or cartilage on specimen.
orientation, section numbering
& inking patterns

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or
Presence of Cartilage
Presence of Cartilage
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bu
tri

189 190
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D

Specimen Processing &

Presence of Cartilage
ot

Numbering
Each Mohs stage has one or
N

more specimens
Large specimens are
subdivided for processing
o

Each subdivision is called a

“section”
D

191 192

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Specimen Processing & Specimen Processing &

Numbering Numbering

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Surgical stages are Multiple tumors from same

at
numbered with Roman patient are distinguished by
numerals (I, II, III…) capital letters

lic
Specimen pieces (sections) IA, IB, IC
are numbered with Arabic
numerals (1,2,3…)

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193 194

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or
Specimen Numbering & Specimen Numbering &
Processing Processing
Subdivide specimens along Numbering systems:
te
reference lines
Clockwise
Number the subdivisions
Top-to-bottom
bu

consistently
Left-to-right
tri

195 196
is
D
ot
N
o
D

197 198

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You now interpret the prepared

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slides

And complete Mohs map

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Suggestions for Your
Surgeon v Histotechnician
First Mohs Cases
The most challenging part of Mohs Progress from:
te
Surgery…
smaller → larger lesions
one tissue piece → multi-section cases
Is NOT the surgery or slide reading
Primary, nodular and cystic BCC’s
bu

It is the tissue processing & slide avoid infiltrating & sclerosing tumors
preparation
tri

201 202
is
D

What the heck

Your First Mohs Cases
were you thinking?
Surgeon Technician
ot

Don’t bite off more than you can chew!

N
o
D

203 204

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Your First Mohs Cases Your First Mohs Cases

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Simple

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Small
Distant from:

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Vital structures
Anatomic danger zones
Need not be Mohs indicated

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or
Your First Mohs Cases
Your First Mohs Cases
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bu
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207 208
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D

Avoid Difficult to Excise

ot

Cases that are difficult to: Temple

N

Excise Canthi
Process Lid margins
Interpret Ala & alar folds
o

Ears
D

209 210

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Difficult to Excise Difficult to Excise

e
Neglected tumors

at
Large tumors
Fixed to bone or cartilage

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up
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or
Difficult to Excise
Difficult to Excise Tumor Fixed to Bone
Neglected Tumors
te
bu
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213 214
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D
ot
N
o
D

215 216

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Tumor Fixed To Cartilage

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at
lic
up
217 218

D
or Avoid

Cases difficult to:

te
excise
process into slides
bu
tri

219 220
is
D

Difficult to Process
Difficult to Process
ot

large tumors need

multiple subdivisions
Very large tumors
N

Need multiple sub-sections

Specimens with cartilage and
thick fat
o
D

221 222

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Difficult to Process Avoid

Cartilage

e
Cases difficult to:

at
excise
process

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histologically interpret

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or
Difficult to Interpret
Avoid

Difficult to:
te
Sclerosing BCC DFSP
excise
process
bu

histologically interpret
sclerosing & spindle cell tumors
squamous cell carcinomas
melanocytic tumors
tri

http://www.atlasdermatologico.com.br

225 226
is
D
ot

You must be able to clear at least

N

-the peripheral margins

o
D

227 228

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Situations To Avoid Situations To Avoid

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at
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D
Situations To Avoid

or Situations To Avoid
te
bu
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231 232
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D

Your First Mohs Cases

ot

Know your level of skill

N

Only select cases you can

properly complete
o
D

233 234

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Remember

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Mohs surgery is perhaps the

at
only surgery that you do
not have to repair!

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or
Recommendations For Recommendations For
Your First Case Your First Case
te
Excise only one tumor You, your technician & staff
Dedicate a half day need to learn the system
bu
tri

237 238
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D
ot

Thank You
N
o
D

239

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