P Recurrence in grafted skin or previously irradiated areas: Resist the desire to undertake repeated Mohs, he advised. “These can be bad. They can be too extensive, and you will invest some time and money and some very stressful moments if you get into this.”
P Ear: For tumors in the concha, “Pay attention to the size, type, and proximity to the external canal. It’s really hard to do Mohs excisions in the ear canal.”
P Eyelid: The thinnest skin on the body, the eyelid is even more fragile on elderly people. “This is a very difficult area for me to cut in Mohs. Instead of applying a lot of pressure, I use a number 11 or 15 blade and do several rounds. Use light pressure because the epidermis has a tendency to fold and pull, making it hard to cut.” Bevelling is not as important here because the skin is so friable that the technician can easily flatten it on the slide.
Topical anesthetic ocular drops help the patient tolerate the surgery much better, and allow the placement of a plastic eye shield anchored with a couple of small sutures. “The eye shield and sutures are left in place while the patient is waiting – I just cover it with a full eye patch.”
P Nose: For lesions on the ala or alar arch, cotton swabs, dental rolls, or even a finger push the tissue outward and give good support for excision. “Notching of ala before surgery is a bad prognosis,” Dr. Garcia said. “It means advanced cancer, and this may not be something you want to get into.”
Dr. Garcia said he had no financial disclosures.