Periocular Mohs micrographic surgery: Results of a dual-site day-surgery service

Abstract

PURPOSE. To assess the feasibility of day-surgery Mohs Micrographic Surgery (MMS) at dual sites. METHODS. MMS now has an established position for the management of skin tumour removal. The literature reports excellent results in terms of tissue preservation, complete tumour excision and recurrence rate. MMS involves an initial stage undertaken by dermatologists. The subsequent reconstructive phase can be undertaken either by the dermatologist or by an oculoplastic surgeon in cases of extensive defects. In the latter cases, special expertise is needed in order to achieve satisfactory cosmetic results. Centres offering MMS are few and are usually located in tertiary referral hospitals. In a large city of 12 million inhabitants like London there is only one centre offering MMS on the National Health Scheme. We have set up a dual-site day-surgery service since 1997, whereby a Mohs trained dermatologist in the first unit undertakes the initial ablative stage. The patient is then transferred to the second location, which is approximately three miles away; a trained oculoplastic surgeon then undertakes the reconstruction the same day. Rarely, defects are deemed too large for reconstruction and the patient discharged on the same day; patients are then admitted as inpatients for reconstruction the following day with oculoplastic, plastic, craniofacial and facio-maxillary services at hand. RESULTS. To date we have operated on 59 patients for removal of basal cell carcinomas (BCC). All patients had a biopsy-proven diagnosis of BCC before being referred to the dermatologist. Following liaison with the Dermatology Unit, surgery was scheduled so that the reconstruction could be undertaken in the Oculoplastic Unit at the second hospital on the same day. All patients' defects were reconstructed successfully. With the longest follow-up being 39 months so far, tumour recurrence has been 0%. CONCLUSIONS. A dual-site day-surgery service seems to be a feasible option where a MMS dermatologist is not present onsite. The logistic problem can be easily overcome with a proper liaison between the departments. A dual-site day-surgery MMS service provides a superior service compared with the 2 mm tumour-free margin excision and delayed surgical repair following histological examination advocated by other authors where MMS is not available on site. It is only with MMS that one can ensure complete tumour excision. Day-surgery is the preferred choice, both for patients and for financial considerations. We would therefore support the establishment of dual-site day-surgery MMS services where the reconstruction is undertaken in hospitals located away from the MMS dermatology unit, provided close collaboration exists between the two units to ensure the smooth transfer of patients.

Guidelines for the management of basal cell carcinoma

“…69 Five-year cure rates of 93AE5% for primary BCC and 90% for recurrent disease have been reported. 64 MMS for BCC performed under local anaesthesia in an outpatient or day-case setting has a good safety record 70,71 and Mohs surgical defects can be repaired by the Mohs surgeon or by facial reconstructive specialists including plastic, 72 otolaryngeal 73 and oculoplastic 74,75 surgeons. The technique is performed using either frozen tissue sections, 76 when resection can take place over a matter of hours, or with formalin-fixed, paraffin-embedded tissues, when the procedure takes place over a number of days.…”

Mohs Surgery for Periocular Basal Cell Carcinoma Without a Mohs Surgeon: The First Series in Hong Kong

“…Modifications of histological preparation in MMS or frozen section techniques [ 18 - 20 ] have been reported, including a multidisciplinary team approach involving the Mohs (ablative) and the reconstructive surgeon in the periocular region [ 21 ]. While we concur with the rationale and use of MMS for the treatment of pBCC, we have been working out how it should be adopted in Hong Kong, where non-melanoma skin cancer is of lower incidence and establishing a dedicated Mohs service is not cost-effective [ 22 ].…”