Mohs Micrographic Surgery – what the gold standard in dermatologic surgery offers us. A Literature Review

Abstract

Introduction and objective: Micrographic Mohs surgery, a highly precise surgical technique, has long been regarded as a cornerstone in dermatology for the treatment of various skin cancers. This review aims to comprehensively summarize the current understanding of the principles and clinical applications of Mohs surgery, with a specific focus on providing insights to clinicians and researchers. State of Knowledge: Mohs surgery is particularly renowned for its unparalleled efficacy in treating basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and other skin malignancies, especially in anatomically challenging areas. The technique involves meticulous removal of cancerous tissue layers while sparing healthy surrounding tissue, facilitated by microscopic examination of surgical margins. Recent advancements in Mohs surgery have led to improved outcomes, with techniques such as immunostaining enhancing the accuracy of tumor detection and minimizing the need for additional surgeries. Materials and methods: This review of studies is based on scientific articles avaible in PubMed, Google Scholar databases and Elsevier. Summary: Micrographic Mohs surgery remains a cornerstone of dermatologic oncology, offering unparalleled precision and cure rates for various skin cancers. Its success lies in its ability to achieve complete tumor removal while preserving maximal tissue integrity and cosmesis. Future research endeavors should focus on refining surgical techniques, optimizing patient selection criteria, and exploring adjunctive therapies to further improve outcomes and patient satisfaction. By advancing our understanding and application of Mohs surgery, we can continue to provide optimal care for patients with skin cancer, ultimately improving their quality of life and prognosis.

Full text

PERKOWSKA, Klaudia, KAŹMIERCZAK, Anna, IZDEBSKA, Wiktoria, SORNEK, Patrycja, BORKOWSKA, Agata,
KIEŁB, Anna, PAWLAK, Igor, MICH, Anna, CIESIELSKI, Radosław and STANEK, Jakub. Mohs Micrographic Surgery – what
the gold standard in dermatologic surgery offers us. A Literature Review. Quality in Sport. 2024;18:53925. eISSN 2450-3118.
https://dx.doi.org/10.12775/QS.2024.18.53925
https://apcz.umk.pl/QS/article/view/53925
The journal has been 20 points in the Ministry of Higher Education and Science of Poland parametric evaluation. Annex to the announcement
of the Minister of Higher Education and Science of 05.01.2024. No. 32553.
Has a Journal's Unique Identifier: 201398. Scientific disciplines assigned: Economics and finance (Field of social sciences); Management and
Quality Sciences (Field of social sciences).
Punkty Ministerialne z 2019 - aktualny rok 20 punktów. Załącznik do komunikatu Ministra Szkolnictwa Wyższego i Nauki z dnia 05.01.2024
r. Lp. 32553. Posiada Unikatowy Identyfikator Czasopisma: 201398.
Przypisane dyscypliny naukowe: Ekonomia i finanse (Dziedzina nauk społecznych); Nauki o zarządzaniu i jakości (Dziedzina nauk
społecznych).
© The Authors 2024;
This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland
Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any
noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open
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The authors declare that there is no conflict of interests regarding the publication of this paper.
Received: 30.07.2024. Revised: 14.08.2024. Accepted: 15.08.2024. Published: 19.08.2024.
1
Mohs Micrographic Surgery – what the gold standard in
dermatologic surgery offers us
A Literature Review
Klaudia Perkowska
E-mail: dr.kperkowska@gmail.com
ORCID: https://orcid.org/0009-0001-7362-4995
Military Medical Institute, Szaserów 128, 04-349 Warsaw, PL
Anna Kaźmierczak
E-mail: a.kazmierczak.1998@o2.pl
ORCID: https://orcid.org/0009-0000-8435-6685
4th Military Clinical Hospital in Wroclaw, Weigla 5, 53-114 Wroclaw, PL
Wiktoria Izdebska
E-mail: wiktoriaxizdebska@gmail.com
ORCID: https://orcid.org/0009-0005-0242-141X
J. Gromkowski Regional Specialist Hospital in Wrocław, Koszarowa 5, 51-149 Wrocław, PL
Patrycja Sornek
E-mail: sornekpatrycja5@gmail.com
ORCID: https://orcid.org/0009-0003-9630-055X
Military Medical Academy Memorial Teaching Hospital- Central Veteran Hospital ul.
Stefana Żeromskiego 113, 90-549 Lodz, Poland

2
Agata Borkowska
E-mail: agata.borkowska.ab@wp.pl
Orcid: https://orcid.org/0009-0008-7347-7762
Military Institute of Aviation Medicine, ul. Zygmunta Krasińskiego 54/56, 01-755 Warsaw,
PL
Anna Kiełb
E-mail: akielb97@gmail.com
ORCID: https://orcid.org/0009-0005-3152-5429
5th Military Clinical Hospital in Krakow, ul. Wrocławska 1-3, 30-901 Krakow, Poland
Igor Pawlak
E-mail: igor.a.pawlak@gmail.com
ORCID: https://orcid.org/0009-0003-1942-9296
Independent Public Hospital in Mińsk Mazowiecki, ul. Szpitalna 37, 05-300 Mińsk
Mazowiecki
Anna Mich
E-mail: aniamich97@icloud.com
ORCID: https://orcid.org/0009-0004-6299-5506
Independent Public Hospital in Mińsk Mazowiecki, ul. Szpitalna 37, 05-300 Mińsk
Mazowiecki
Radosław Ciesielski
E-mail: radoslaw.ciesielski@yahoo.com
ORCID: https://orcid.org/0000-0002-3458-2024
Independent Public Hospital in Mińsk Mazowiecki, ul. Szpitalna 37, 05-300 Mińsk
Mazowiecki
Jakub Stanek
E-mail: jakubstanek22@gmail.com
ORCID: https://orcid.org/0000-0002-9450-7261
Medical University of Lodz, al. Tadeusza Kościuszki 4, 90-419 Łódź
ABSTRACT
Introduction andobjective:
Micrographic Mohs surgery, a highly precise surgical technique, has long been regarded as a
cornerstone in dermatology for the treatment of various skin cancers. This review aims to
comprehensively summarize the current understanding of the principles and clinical
applications of Mohs surgery, with a specific focus on providing insights to clinicians and
researchers.

3
State of Knowledge:
Mohs surgery is particularly renowned for its unparalleled efficacy in treating basal cell
carcinoma (BCC), squamous cell carcinoma (SCC), and other skin malignancies, especially in
anatomically challenging areas. The technique involves meticulous removal of cancerous
tissue layers while sparing healthy surrounding tissue, facilitated by microscopic examination
of surgical margins. Recent advancements in Mohs surgery have led to improved outcomes,
with techniques such as immunostaining enhancing the accuracy of tumor detection and
minimizing the need for additional surgeries.
Materials and methods:
This review of studies is based on scientific articles avaible in PubMed, Google Scholar
databases and Elsevier.
Summary:
Micrographic Mohs surgery remains a cornerstone of dermatologic oncology, offering
unparalleled precision and cure rates for various skin cancers. Its success lies in its ability to
achieve complete tumor removal while preserving maximal tissue integrity and cosmesis.
Future research endeavors should focus on refining surgical techniques, optimizing patient
selection criteria, and exploring adjunctive therapies to further improve outcomes and patient
satisfaction. By advancing our understanding and application of Mohs surgery, we can
continue to provide optimal care for patients with skin cancer, ultimately improving their
quality of life and prognosis.
Keywords: mohs micrographic surgery; basal cell carcinoma; dermatosurgery; cancer
Introduction
Dermatosurgery is an interdisciplinary field of dermatology focused on the surgical treatment
of various skin diseases. Over the past few decades, it has significantly advanced both
technologically and procedurally. Modern dermatosurgery encompasses a wide range of
procedures, from simple removal of skin lesions to advanced reconstructive techniques. In
this review, we will examine the role of dermatosurgery in treating different skin conditions,
highlighting the latest techniques, their applications, and future development prospects.
This analysis will provide a better understanding of the role of dermatosurgery in modern
medicine and its impact on improving patients' quality of life. In the following work, I will
present the most important technique in dermatosurgery – Mohs micrographic surgery. [1]
History
The excision technique is named after its pioneer, Dr. Frederic E. Mohs, who lived from 1910
to 2002. As a medical student, Mohs studied the effects of lymphocyte infiltration on tumor
development. During these studies, he accidentally applied zinc chloride therapy and
discovered that injecting it into tissue led to its histological fixation, allowing for detailed

4
cytological examination under a microscope [2]. In 1932, he used this substance to coagulate
basal cell carcinoma and squamous cell carcinoma tissue.
He then removed the necrotic tissue. This process was repeated in horizontal layers until a
layer without malignant tissue was obtained in the histopathological image.
Each layer took one day because the paste needed time to bind the tissue before removal.
Patients with large tumors, requiring the removal of multiple layers, had to return for
treatment daily, often for several days. The applied paste caused pain, local inflammation, as
well as fever and lymph node enlargement [3,4].
Procedure description
Tumor removal layer by layer and meticulous examination of the undersurface of each layer
under the microscope through systematic use of frozen sections ensures complete elimination
of the tumor, including its "hidden" extensions, while simultaneously maximizing
preservation of healthy tissue. Mohs micrographic surgery on fresh tissue is typically
employed for most tumors, but for melanomas, a safer technique using fixed tissue is
preferable, as all incisions are made in fixed (dead) tissue. This avoids the risk of
dissemination of highly transplantable melanoma cells that could be cut through due to
clinically invisible extensions [5].
1. First, the area containing the tumor is accurately marked, followed by local anesthesia
administration—usually buffered lidocaine with epinephrine. After anesthesia, visible
portions of the tumor are removed using selected surgical tools such as a scalpel or a
curette.
2. Subsequently, margins of the first stage are removed, with the blade set at a 45-degree
angle to the skin. This allows for proper alignment of the outer edges of the tissue
sample during preparation for histopathological examination. During the excision of
the first layer, markings are made at the 12, 3, and 6 o'clock positions to facilitate
further orientation and locating any remaining tumor (if observed during microscopic
examination). After removal, the tissue is divided into smaller fragments and marked
to precisely determine the tumor's location.
Figure 1. Blank Mohs Map [6]

5
3. The initial step in processing the tissue involves flattening the surgical specimen so
that the beveled peripheral edges are aligned in the same plane as the deep margin.
4. The tissue is flattened, facilitating its examination under the microscope, where
staining is used to assess the presence of tumor cells.
5. If residual tumor cells are noticed under the microscope, indicating that the surgeon
did not remove the entire tumor, the Mohs micrographic surgery process continues.
Another tissue sample is taken from the area where these tumor cells were found. A
new tissue margin, usually 1–2 mm wide, is excised around this area and meticulously
marked for microscopic purposes. If the tumor is found only in deeper tissue layers,
the surgeon may proceed with another stage only in that area, without enlarging the
width of the surgical defect.
6. After completely removing the tumor, the Mohs surgeon prepares to reconstruct the
surgical defect. Various methods are employed to close both simple and more intricate
skin defects, including complex linear closures, skin flap techniques, and skin grafts.
Factors such as the location of the anatomical defect, the depth of the wound, the
availability of nearby skin, and neighboring anatomical structures are considered when
planning how to repair the defect, as these factors influence both function and
appearance. In some cases, treatment may require more than one stage for more
complex cases [7].
Figure 2. Mohs micrographic surgery. A Demarcation of the visible tumor and excision
with a 1–2 mm margin. The incision is made with the scalpel angled at 45 degrees,
allowing for the flattening of surgical margins on the same plane. (B), (1) Surgical
specimen. The surgical margins to be examined correspond to all lateral and deep external
areas of the fragment. (2) The red arrows indicate the "flattening" of the margins to the
same plane. (3) After the fragment is frozen in the cryostat, "horizontal" histological
sections are performed, allowing for the analysis of 100% of the lateral and deep margins.
The three dark spots correspond to the "roots" of the tumor seen on microscopic
examination. (C), The remaining tumor "roots" are excised for further analysis under the
microscope. [5]

6
Figure 3: Flattening, Staining, and Sectioning Before Histopathological Evaluation of the
Excised Layer. [5]
The most commonly used tissue stains in Mohs surgery are hematoxylin and eosin (H&E) and
toluidine blue. Although most Mohs surgeons routinely use H&E, a significant number of
specialists prefer toluidine blue for processing basal cell carcinoma (BCC) because the
mucopolysaccharides and hyaluronic acid associated with BCC stain metachromatically to a
magenta color. [8,9,10].
INDICATIONS FOR MOHS SURGERY
Mohs micrographic surgery (MMS) is employed in cases of skin tumors with a high risk
where standard excision does not provide a complete determination of tumor margins and
does not guarantee the total removal of the tumor lesion [2]. Increasing evidence suggests its
efficacy in treating both primary and recurrent basal cell carcinoma and squamous cell
carcinoma, especially in cases with nerve involvement [5]. Additionally, it allows for the
treatment of Bowen's disease, melanoma, verrucous carcinoma, cuniculatum carcinoma, and
benign tumors like onychomatricoma and glomus tumor [11,12,13]. This method is also
particularly effective in the therapy of fibrosarcomatous dermatofibrosarcoma protuberans,
especially in high-risk areas such as the head and neck, where wide local excision may be
difficult to perform [4]. The Mohs technique is especially suitable for high-risk skin tumors
prone to recurrence and in cases where preserving the maximum amount of healthy tissue is
essential.

7
To assist clinicians in determining whether a particular tumor should be treated with this
method, guidelines have been developed regarding the appropriate use criteria (AUC) for
Mohs surgery. They are based on body location, patient characteristics, and tumor
characteristics. [14,15,16].
Body areas within the "H" zone, such as:
• Central part of the face, eyelids, corners of the eyes, eyebrows, nose, lips, chin, ears,
and perioral areas.
• Genitalia.
• Hands, feet, ankles, nail units.
• Breasts and areolae.
Figure 4. Illustrates anatomic risk areas. Red: High-risk areas. [3]
Characteristics of patients at increased risk include:
• Decreased immunity.
• Genetic syndromes (such as basal cell nevus syndrome and xeroderma pigmentosum).
• Skin previously exposed to radiation.
• Patients with a history of high-risk tumors.
Characteristics of tumors include:
• Positive margins after recent excision.
Aggressive features posing a high risk of basal cell carcinoma (BCC) recurrence:
• Aggressive histologic subtype (morpheaform, infiltrative, micronodular).
• Perineural involvement.
• Metatypical or keratotic.
Aggressive features of squamous cell carcinoma (SCC) include:
• Poorly or undifferentiated tumor (characterized by high nuclear pleomorphism, high
mitotic rate, or low keratinization).
• Perineural or perivascular involvement.
• Presence of spindle cells.
• Breslow depth of 2 mm or more.
• Clark level IV or higher. [14,15,16]

8
Advantages of using mohs technique
Mohs micrographic surgery (MMS) stands out for its exceptionally high efficacy in treating
skin cancers. Additionally, due to minimal removal of healthy tissue, it ensures excellent
cosmetic outcomes. [17] The five-year recurrence rates following various treatment methods
are as follows: Mohs micrographic surgery - 1.0%, surgical excision - 10.1%, curettage and
electrodesiccation - 7.7%, radiation therapy - 8.7%, and cryosurgery - 7.5%. [18] This
difference in local recurrence rates in favor of Mohs micrographic surgery applies to primary
SCC of the skin and lips (3.1% compared to 10.9%), SCC of the ear (5.3% compared to
18.7%), locally recurrent (previously treated) SCC (10% vs 23.3%), SCC involving the
perineum (0% vs 47%), SCC larger than 2 cm (25.2% vs 41.7%), and poorly differentiated
SCC (32.6% vs 53.6%). [18]
The preservation of healthy tissue has always been a focus of skin cancer surgery. Numerous
studies have demonstrated that Mohs micrographic surgery (MMS) conserves tissue
compared to standard excision. A recent study on infiltrative basal cell carcinomas (BCCs)
found that MMS preserved 46% more healthy tissue than standard surgery. [21] Another
study showed significant preservation of healthy tissue (56–86%) for facial BCCs near free
margins compared to recommended standard excision margins. [22] Similarly, Gniadecki et
al. demonstrated that MMS resulted in 43% and 45% smaller defects compared to standard
excision for primary BCCs (4 mm margins) and high-risk recurrent BCCs (6 mm margins),
respectively. [23]
In a further study, a retrospective cohort study was conducted to assess the risk of local
recurrence and progression in 614 patients with invasive or in situ melanoma who underwent
Mohs micrographic surgery (MMS). Local recurrence was observed in 0.34% of cases (2 out
of 597 lesions), with a mean observation time of 1026 days (2.8 years). An increase in the
degree of advancement was also noted in 34 cases out of 614 lesions (5.5% of all cases), with
97% of these changes (33 out of 34) being detected by the Mohs surgeon before
reconstruction. [24]
Clinical data of patients diagnosed between September 2014 and March 2017 at the
Dermatology Department of Policlinico Sant'Orsola-Malpighi University of Bologna were
retrospectively evaluated. Among 285 patients treated with Mohs micrographic surgery
(MMS), disease recurrence occurred in 9 cases (3.1%). In contrast, among 378 patients treated
with traditional surgical methods, 53 experienced disease recurrence (14%). In 13 of these
patients, residual tumor was found at the deep or lateral margins of the main surgical
specimen. [25]
Complement to treatment
In today's era, we can perform lesion excision procedures with even greater precision thanks
to advancements in technologies such as Reflectance Confocal Microscopy (RCM), Optical
Coherence Tomography (OCT), High-Frequency and High-Resolution Ultrasound
(HFHRUS), and Raman Spectroscopy (RS). These technologies promise to enhance
diagnostic accuracy and provide real-time visualization of excised tissue, thereby improving
tumor margin assessment. [26]. Additionally, we can utilize skin bioprinting, a transformative

9
technology used to fabricate biomimetic scaffold architectures mimicking human skin. This
allows for achieving even better visual outcomes. [27]
In comparison to other surgical methods with postoperative repair, Mohs micrographic
surgery costs about the same as simple excision done in the office, with permanent section
postoperative margin control. It's also less costly than excisions with intraoperative margin
control using frozen sections, whether performed in a private office or an outpatient surgical
facility. [28] The potential synergy of artificial intelligence with these innovations could
revolutionize the detection of skin cancers and improve the effectiveness of skin cancer
treatment. [26]
Complications
Although Mohs micrographic surgery is considered the gold standard in dermatologic
surgery, it has its drawbacks. Some of these complications stem directly from the method
itself, while others are due to the medical procedures commonly used in such treatments. The
first complication is contact dermatitis, which can be caused by disinfectants, latex gloves,
adhesives in dressings, or sutures [29]. Another potential issue is the toxicity from anesthetic
overdose, vasovagal syncope, and reactions to epinephrine [30]. Bleeding and hematoma
formation are complications that can often be managed by discontinuing anticoagulant
medications in the patient. If the patient is not on such medications and bleeding occurs, we
use local hemostatic agents, electrosurgery, thermal cauterization, or manual pressure [31].
When blood flow to the tissue is impaired, necrosis may appear on the edges of the sutured
skin. This is a possible consequence of using the MMS technique in wounds that are closed
primarily, with skin flaps, or grafts [32]. There is no concrete evidence that postoperative
antibiotics prevent infections [33]. However, non-primary wound closures may require
antibiotic prophylaxis [34]. Additionally, there may be suture dehiscence and the separation
of wound edges. If the edges are fresh and uninfected, re-suturing can be considered [35]. One
of the most intriguing complications can be the interactions with implantable electronic
devices (IEDs). These interactions arise from the use of electrosurgery and electrocautery to
achieve hemostasis. Currently, modern implantable electronic devices generally pose a low
risk of electromagnetic interference during electrosurgery. Nevertheless, it is advisable to
minimize this risk. Instead of traditional electrosurgery, the use of electrocoagulation or
bipolar electrosurgery is preferred to assist with hemostasis during MMS procedures.
Summary
Mohs micrographic surgery is the most advanced method in dermatologic surgery. It allows
for achieving a smaller excision margin, more precise lesion margins, and reduces the risk of
malignant lesion recurrence. It enables the removal of tumors from hard-to-reach areas.
Recently, with access to reliable immunohistochemical staining, Mohs micrographic surgery
has also proven to be highly effective in treating some forms of malignant melanoma, such as
lentigo maligna melanoma, superficial spreading melanoma, and thin melanoma. The tissue-
sparing properties of Mohs micrographic surgery make it particularly useful in areas of
functional and aesthetic significance, such as the head and neck, perianal and genital areas,
hands, and feet. With the increasing incidence of non-melanoma skin cancers, as well as

10
melanomas themselves, the need for innovation and improvements in Mohs technique will
continue to grow. At this moment, it remains a pioneer among surgical methods for lesion
removal [36].
All authors have read and agreed with the published version of the manuscript.
Conceptualization: Klaudia Perkowska, Anna Kaźmierczak
Methodology: Klaudia Perkowska, Anna Kaźmierczak, Wiktoria Izdebska
Software: Patrycja Sornek
Check: Wikoria Izdebska, Agata Borkowska, Anna Kiełb
Formal analysis: Igor Pawlak
Investigation: Patrycja Sornek, Agata Borkowska
Resources: Klaudia Perkowska, Anna Mich, Radosław Ciesielski
Data curation: Anna Kiełb, Anna Kaźmierczak
Wirting-rough preparation: Patrycja Sornek, Agata Borkowska
Supervision: Anna Kiełb Igor Pawlak
Writing-rewiev and editing- Anna Mich, Radosław Ciesielski
Project administration: Klaudia Perkowska
All authors have read and agreed with the published version of the manuscript.
Funding Statement: The Study Did Not Receive Special Funding.
Institutional Review Board Statement: Not Applicable.
Informed Consent Statement: Not Applicable.
Data Availability Statement: Not Applicable.
Conflict Of Interest: The authors declare no conflict of interest.
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