BY DR RODGER DOWN, MBBS, FRCS, FRACS, MD (LOND)
Is Mohs surgery better than standard plastic or reconstructive surgery? In my opinion, its use is a controversial marketing tool.
Proponents state that Mohs surgery is ‘tissue sparing’; only the cancer is removed, without an additional margin of ‘normal skin’ being taken around the cancer, which preserves all healthy skin and keeps the surgical site as small as possible.
Mohs is not more ‘tissue sparing’. It is standard practice for plastic or reconstructive surgeons to remove ‘only the cancer’ with an appropriate margin of 1mm for BCC and 1-2mm for squamous cancers of the skin, including deep tissue clearance. So, what is the difference? Mohs takes all day and is very expensive!
The Mohs surgeon claims to minimise the extent of the resection to make closure easier. But it is standard plastic surgical practice to draw a 1-2mm clearance of the macroscopic tumour edge, which is very obvious to the skilled eye, before undertaking any cutting. So why can’t a MOHS surgeon do this?
Mohs:
- Increases the chance of an inadequate initial resection, which will be found when the specimen is sent for frozen section.
- A pathologist will then examine the edges for complete clearance, which takes around two hours. A frozen section is also not the most reliable method to examine the specimen for possible residual cancer. The path report is often incorrect due to distortion, folding and the limitations of the process itself. If formalin slides are made, this delays closure for at least 24 hours.
- Necessitates an initial dressing and delay in primary closure of the skin, sometimes overnight, increasing the risk of infection.
- It may also interfere with primary defect flap repair surgery.
A skilled Specialist Surgeon will achieve good cosmetic removal of the cancer within 30 minutes, resulting in early discharge without the MOHS ‘razzamatazz’.
It is my view that Mohs is a very expensive gimmick, because multiple and expensive procedures are added to a simple procedure. It confers no demonstrable improvement in the cure rate for skin cancer and is time-consuming.
