- Kishwer Nehal, MD
Kishwer Nehal, MD
- Associate Professor of Dermatology
- Cornell Weill Medical College
- Erica Lee, MD
Erica Lee, MD
- Instructor of Dermatology
- Weill Cornell Medical College
Mohs micrographic surgery (MMS) is a specialized surgical technique for removing locally invasive, high-risk skin cancers. MMS provides high cure rates with maximal preservation of unaffected tissue [1-4]. In contrast to standard excision, in which only a small portion of the margins are evaluated, in MMS, specimens are cut in horizontal sections that allow the evaluation of the entire peripheral and deep margins of the tumor.
The most common malignancies treated with MMS are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). MMS is also used to remove other skin malignancies such as dermatofibrosarcoma protuberans (DFSP), microcystic adnexal carcinoma, extramammary Paget disease (EMPD), and lentigo maligna.
The MMS technique and its indications will be discussed in this topic review. Alternative treatments for skin tumors are discussed separately. (See "Treatment of basal cell carcinomas at high risk for recurrence" and "Treatment and prognosis of cutaneous squamous cell carcinoma" and "Recognition and management of high-risk (aggressive) cutaneous squamous cell carcinoma" and "Dermatofibrosarcoma protuberans: Epidemiology, pathogenesis, clinical presentation, diagnosis, and staging" and "Microcystic adnexal carcinoma" and "Lentigo maligna: Clinical manifestations, diagnosis, and management".)
The original technique, developed by Frederic Mohs in the 1930s, was called "fixed-tissue technique" or chemosurgery [1,2,5]. It involved the overnight application of a zinc chloride paste to the tumor, which produced tissue necrosis but retained the microscopic architecture. The devitalized, preserved tissue was subsequently excised in a saucer-shaped layer and marked with colored dyes for orientation and correlation on a map. The specimens were then manually flattened, sectioned in the horizontal plane, and stained for histologic examination. In areas of residual tumor, zinc chloride was reapplied overnight and the process repeated until clear margins were achieved.
In the following years, Mohs surgery evolved from the fixed-tissue to a "fresh-tissue technique" that used frozen sections of the excised tissue and was initially employed to treat eyelid cancers with a five-year cure rate of 100 percent [2,4]. The fresh-tissue technique allows single-day excision and repair of the surgical defect in most cases and has become the standard technique for Mohs surgery .
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- Nijhawan RI, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg 2015; 41:499.
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- HISTORICAL PERSPECTIVE
- SURGICAL TECHNIQUE
- Excision and mapping
- Frozen tissue processing
- Histologic examination
- Technical pitfalls
- General indications
- Specific indications
- ADVANTAGES AND DISADVANTAGES
- PREOPERATIVE EVALUATION AND MANAGEMENT
- Preoperative consultation
- Antibiotic prophylaxis
- SUMMARY AND RECOMMENDATIONS