Length-to-width ratio in Mohs defects: what is the golden rule?

A length-to-width ratio (LWR) of 3:1 for linear closures is often cited in the literature. However, there are limited studies evaluating this ratio in relation to various surgical sites. This study analyzes LWRs for 3318 patients undergoing Mohs micrographic surgery (MMS) and linear repair to identify the average LWRs stratified by patient age, anatomic location, gender, and surgeon. Average LWRs ranged between 2.89 and 3.82. The LWR for all anatomic sites averaged between 3:1 and 4:1, except for closures on the trunk. Locations with the highest LWR included the cheek, ear, and perioral sites.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Eccrine Porocarcinoma Treated by Mohs Micrographic Surgery: Over 6-Year Follow-up of 12 Cases and Literature Review.

BACKGROUND: Eccrine porocarcinoma (EPC) has a poor prognosis after standard wide local excision (WLE), with 20% local recurrence, 20% regional and 12% distant metastatic rates. Mohs micrographic surgery (MMS) has been used as a promising treatment. OBJECTIVE: To review the use of MMS for EPC and assess treatment outcomes. MATERIALS AND METHODS: This was a retrospective case series of 12 EPC patients treated by MMS between 1984 and 2013 in the institution. Furthermore, a literature review revealed an additional 17 cases of EPC managed by MMS. RESULTS: Of 29 cases of EPC treated by MMS, outcome was established in 27 cases. The patients had a significantly longer mean follow-up period of 6 years (range, 4-206 months), as compared with 19 months (range, 2-48 months) in reported cases. Two patients had regional lymph node metastasis after MMS. The regional metastatic rates to lymph nodes were 7% (2/27). There was no local recurrence, distant metastasis, or disease-specific death in the 27 cases studied. CONCLUSION: To the best of the authors' knowledge, this is the single largest case series of EPCs treated by MMS and the authors' data demonstrated that MMS may be superior to the standard WLE.

Evaluation and management of hypertension in the perioperative period of Mohs micrographic surgery: a review.

BACKGROUND: While patients' hypertensive problems are usually actively and effectively managed by their primary physician, the dermatologic surgeon can still be affected by hypertension where the condition is unrecognized or uncontrolled. Hypertension is an important contributor to both bleeding and hematoma formation during and after surgery, ultimately affecting functional and cosmetic outcomes. OBJECTIVE: To extensively review the literature on perioperative management of the hypertensive patient as relates to the dermatologic surgeon. MATERIALS AND METHODS: An updated and comprehensive literature review, focusing on current diagnostic guidelines, practice by specific dermatologic surgery groups and management recommendations, was conducted. RESULTS: Review of the literature does support generalized guidelines for the management of hypertensive patients in the Mohs Micrographic Surgery (MMS) setting; however data on implementation and outcomes by specific dermatologic surgery groups is variable and lacking. CONCLUSIONS: The treatment of nonmelanoma skin cancers with MMS is now routine, and fortunately can be performed quite safely. There are still improvements to be made however, in managing perioperative hypertension-both in making patients aware of their condition and in treating it effectively. Practicing these measures can promote patients' overall health and the efficiency of the dermatologic surgeon's practice.