After tumor removal, amputation of toes provided skin flaps for a functional foot. Photos courtesy Dr. Roger I. Ceilley
Tips to Ensure Successful Mohs Surgery
I can't overemphasize the importance of documentation, and following the procedures for [the Occupational Safety and Health Administration] and quality control. This is serious stuff, and if you are going to do Mohs surgery, you need to do it properly," Dr. Ceilley said.
Procedures must be fully explained to patients. Use an analogy that they can understand, such as that of a dandelion: If you don't pull out the weed with all of the roots, it will grow back.
Once the patient is in the operating room, the surgeon has to remember not to perform the repair until the tumor has been entirely removed. It may even be a good idea to wait until the next day to finish a procedure, or consider doing a partial repair to last until the evaluation is complete.
After a layer is removed, pressure should be put on the wound before cautery. "I take the amount of time it takes me to divide, mark, and map a specimen, and then go back and cauterize," Dr. Ceilley said. "It takes you half as long to do the cautery, and you char less tissue."
A Mohs surgeon should not be afraid to ask for help, whether from surgical colleagues or a dermatopathologist. Cultivate a relationship with a good dermatopathologist, because some poorly differentiated tumors and difficult squamous cell cancers are hard to read, he said.
If a tumor is aggressive, the surgery should be equally aggressive. In those cases, "I might do paraffin-embedded slides, special stains, and take extra tissue as needed," Dr. Ceilley noted.
Last but not least, physicians need to remember that bad days will happen. They should try to anticipate problems and have backup options in mind, he emphasized. "Some of the repairs that I could do, I will refer because I know head and neck surgeons who would do the surgery more effectively."