Global Insights into Mohs Practice and Facial Reconstruction

In this engaging interview, Dr Walayat Hussain discusses international variations in Mohs practice and shares insights from his session, “International Perspectives on Mohs & Facial Reconstruction,” presented at the 2023 American College of Mohs Surgery (ACMS) Annual Meeting. He emphasizes standardized care, patient expectations, and innovative techniques like "Twilight Mohs." Discover strategies to optimize outcomes in facial reconstruction and enhance patient-centered care.

Walayat Hussain, BSc, MBChB, MRCP, FRACP, FACMS, is a consultant dermatologist, dermatologic surgeon, and Mohs surgeon at Leeds Teaching Hospitals NHS Trust in Leeds, UK.

The Dermatologist: What are some key variations in Mohs practice and skin cancer service around the world that stand out to you?

Dr Hussain: What was interesting is that colleagues from across the world, when we got together, we realized that we all had the same problems, the same challenges despite where we practiced in the world. One of the things that the ACMS was very keen on, similar to the British Society for Dermatological Surgery (BSDS), was the standards that we felt people should adhere to or strive toward when delivering skin cancer services. So, if you see Mohs surgery in the United Kingdom, you would be confident that the same sort of surgery would take place in the United States and worldwide. Therefore, when someone says they're seeing a Mohs surgeon, they know what that entails. Mohs surgery involves the dermatologic surgeon who diagnoses the skin cancer, treats it, assesses the pathology under the microscope, and invariably does the reconstruction.

The entire journey from seeing the patient at the start to the finish is all within the remit of dermatology. Now, obviously, different healthcare providers perform Mohs surgery differently. It's a very labor-intensive process, and what we found was that we're very fortunate, in the United Kingdom for example, it's provided free of charge by the National Health Service. However, due to limited resources, for example, the ability to provide Mohs is a bit more available, if you will, in the healthcare system in the United States, primarily because it's privately funded. We've also found that in different parts of the world, different health care systems provide Mohs surgeries slightly differently in terms of provision and accessibility. And, of course, it's all about resources, isn't it? Everyone across the world faces the same problem of limited resources, regardless of how they're provided, and with increasing demand, it's about determining which patient will benefit the most from the technique you can offer them. So, not exactly rationing, but rather optimizing the resources at our disposal.

The Dermatologist: What international strategies can surgeons learn from when it comes to the repair of simple and complex Mohs defects on the face?

Dr Hussain: We're very fortunate. The ACMS is internationally regarded as the gold standard fellowship training in Mohs surgery. And, of course, everyone at the meeting in Seattle, is a member of the ACMS, which means we've all received rigorous training in skin cancer diagnosis, pathology, and reconstruction. I think the key takeaway that we learned throughout the conference was managing patient expectations. As long as you manage your patients' expectations, then that's the most important thing. People have different aesthetics and demands. We're living in a very social media-driven world, and people want to look perfect after their surgery. That's our goal as well. However, it's crucial to have realistic expectations of what you can provide your patients after they've recovered from their surgery. We strive to achieve invisible healing, which isn't truly possible. Therefore, we do our very best to maintain contour and function, and provide the best outcomes.

But it's interesting; we had a productive discussion about how as surgeons, we often aim for perfection, and we may want to do a little bit more for a patient to achieve that 1% improvement further down the line. However, the patient may be content with something much simpler than what the surgeon is striving for. And it's not about the surgeon; it's about the patient. So, you must bring the patient to a level where they're happy and comfortable. Some people will be content with something that we might think, "Oh, I would like to do that again or do something slightly better." But the patient says, "No, this is great. I'm delighted."

Conversely, you might have performed what you consider to be an outstanding reconstruction on a patient in a challenging area, and yet the patient may be very concerned about a tiny minor issue – something you may consider minor, like a blood vessel or color change – but it has a significant impact on the patient. It's all about managing expectations, and this applies across the world in terms of how we approach it. During the meeting, we discussed small surgical tips on how to improve contour, shape, and color, and how to strive for as normal a result as possible after skin cancer surgery.

The Dermatologist: What are the major nuances in surgical techniques that minimize complications and optimize outcomes in facial reconstruction?

Dr Hussain: From an individual standpoint, I talked about certain flap reconstruction techniques, which I'm very comfortable performing. I often tell my patients that fixing a hole created after skin cancer removal is much like cooking a lasagna. If you asked 5 Michelin-star chefs about the best way to prepare a lasagna, each one would provide a slightly different variation, based on their techniques and what works for them. Similarly, through time and experience, you discover that what works well in your hands may not work as effectively in someone else's hands.

One significant aspect we found, and which we're fortunate to implement in Leeds, is what we call "Twilight Mohs." Most Mohs surgeries are typically performed under local anesthesia, where the patient remains fully awake and returns home after the procedure; it's office-based surgery. However, there are some patients, as I encounter in my practice, who desire Mohs surgery but are extremely apprehensive about undergoing it under local anesthesia due to a fear of needles. While referring them for general anesthesia and a different specialty is an option, it means they wouldn't benefit from the advantages of Mohs surgery on the same day.

In Leeds, we've established a system that offers patients heavy sedation, a kind of twilight state. It's not quite a general anesthetic, but it heavily sedates them. The Mohs surgery is performed in the usual manner, the sedation is paused while they're not being operated on, so they become fully awake again, and then the sedation is resumed when they go back for surgery, making them much more comfortable. We've termed this approach the Twilight protocol, and it has been highly successful in Leeds. It's a significant game-changer for patients who are particularly anxious or needle-phobic, allowing them to benefit from Mohs surgery in a much more comfortable manner since they can't tolerate local anesthesia. This was one of the key highlights of the meeting and was well received.

The Dermatologist: Are there any tips or insights you would like to share with your dermatologist colleagues regarding your session at ACMS or international strategies for Mohs?

Dr Hussain: I believe it's important to ensure that both the ACMS and the BSDS, as national organizations, emphasize standards. The term "Mohs surgeon" isn't currently protected, meaning anyone can claim to be a Mohs surgeon. Therefore, it's crucial to ensure that patients understand the qualifications, training, expertise, and level of experience of the person performing their surgery. Ultimately, you want to ensure that anyone operating on a patient's face possesses the necessary skills and experience to handle any situation.

Reference
Hussain W. International perspectives on Mohs & facial reconstruction. Presented at: American College of Mohs Surgery (ACMS) Annual Meeting; May 4–7, 2023; Seattle, WA.