Mohs Removals

In the latest "Surgical Challenge" department (May 2003, pp. 36 and 37), the clinical photograph shows two small defects, the largest of which is about one eyebrow width in size (approximately 0.5 cm). The Mohs removals weren’t indicated on flat facial skin for very small tumors of different cell type, which almost could not be contiguous. Also, removal of the skin bridge between the defects followed by undermined layer closure in a vertical direction is the indicated (non-complex) closure. Note also the upper eyelid laxity, which assures the simpler procedure can be easily done. — Thomas G. Hill, M.D. Decatur, GA AUTHOR'S REPLY In response to Dr. Hill’s comments, there are several issues that should be considered. First, although this column isn’t focused on choosing proper excision methods, I’ll briefly address Dr. Hill’s comment regarding improper use of Mohs surgery. The indications for Mohs surgery derive from its ability to precisely and definitively remove tumors and its significant tissue-sparing capability. Tumors that fit the indications for Mohs surgery include: recurrent tumors, incompletely excised tumors, certain histologic subtypes of primary tumors such as sclerosing BCC or poorly differentiated SCC, locations with high recurrence or metastatic potential, size greater than 2 cm, neglected tumors, tumors with indistinct clinical margins, rapid or aggressive growth patterns, lesions in previously irradiated skin, tumors in immunosuppressed patients, BCC nevus syndrome patients and tumors requiring maximal tissue sparing. In the case presented, the two tumors were adjacent to the lateral eyebrow (see photo). Mohs was performed to minimize excessive tissue destruction in an area close to the orbital margin. Although the photo shows a fair amount of tissue laxity on the upper eyelid, a noticeable asymmetry may have resulted if these two tumors were excised with 3-mm to 4-mm margins. Also, even though the temporal nerve and artery are located several cm laterally, the risk of damage was considered. Second, with regard to the choice of repair, the column addressed other, simpler repair options. It’s true that a non-complex closure may be a viable choice. However, as stated in the column, eyebrow asymmetry or a much larger conspicuous scar perpendicular to the eyebrow may have resulted. Dr. Hill states that there is significant laxity in the upper eyebrow; however, this may be falsely apparent since this photo was taken after the anesthetic was injected, resulting in the patient’s eyelid swelling. Often, it’s difficult to evaluate the pre-operative wound and neighboring skin from a close–up photo. A larger photograph of the entire left side of this patient’s face may have better explained why this repair was chosen. — Lance Brown, M.D. New York, NY