What is the physician assistant’s role in Mohs micrographic surgery? Naura Shah, PA-C; Amor Khachemoune, MD, FAAD, FACMS

Physician assistants (PAs) play a large role in preoperative consultations and postoperative evaluations of patients undergoing Mohs micrographic surgery, but, their role during intraoperative care remains somewhat controversial. This article is a basic overview for beginning Mohs PAs, who do not perform this specialized and time-consuming technique on their own, but work in many capacities alongside the Mohs surgeon. Mohs PAs’ degree of involvement may vary from one setting to another, but they can help a Mohs practice by increasing efficiency and quality of patient care.1 INDICATIONS FOR MOHS SURGERY More than 3.5 million cases of nonmelanoma skin cancers are diagnosed annually in the United States.2 New cases of skin cancer outnumber the combined incidence of breast, prostate, lung, and colon cancer.3 The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Although the rate of melanoma is much lower than that of nonmelanoma skin cancers, melanoma is increasing, and accounts for 75% of skin cancer deaths.3 Mohs micrographic surgery is a commonly chosen technique for nonmelanoma skin cancers because histological margins can be controlled and the maximum amount of healthy tissue preserved. The 5-year recurrence rate after Mohs surgery for primary basal and squamous cell carcinomas is less than 1%; the rate is 5% to 10% for recurrent nonmelanoma skin cancers.4 The Mohs technique allows the highest curative rates for certain types of skin cancers as well as preserving cosmetic appearance and bodily functions. Patients can also get immediate satisfaction that their tumor was completely removed in one setting. Other indications for Mohs surgery include basal cell nevus syndrome and a variety of cutaneous tumors. Mohs Naura Shah practices at Premier Dermatology in Ashburn, Va. Amor Khachemoune is a program director of the procedural dermatology fellowship at the State University of New York Downstate; a dermatopathologist and Mohs micrographic surgeon at Premier Dermatology in Ashburn, Va.; and on the dermatology service at the Veterans Affairs Medical Center and SUNY Downstate Health Sciences Center, both in Brooklyn, N.Y. The authors have disclosed no potential conflicts of interest, financial or otherwise. Michael D. Overcash, MPAS, PA-C, department editor DOI: 10.1097/01.JAA.0000458864.63312.70 Copyright © 2015 American Academy of Physician Assistants


surgery is considered a first-line treatment or superior treatment for: • dermatofibrosarcoma protuberans, a rare, slow-growing tumor that can be locally destructive with tentacle-like extension into tissue • sclerosing sweat duct carcinoma, a malignant eccrine tumor that is also locally destructive • atypical fibroxanthoma, a low-grade malignant tumor seen on sun-damaged skin on the scalp and neck of older adults. Mohs surgery is particularly useful for nonmelanoma skin cancers on the face, scalp, neck, ears, genitalia, hands, and feet. General indications for Mohs surgery include high-risk cancers such as melanomas on the trunk and extremities, and rapidly growing skin cancers that are large in size with poorly defined edges.5 PREOPERATIVE PREPARATION Ideally, hold a consultation with the patient on a separate designated day. Explain to the patient how to prepare for surgery, as well as what to expect during and after the surgery. This may alleviate any anxiety or apprehensions the patient has about Mohs surgery. Tell patients they should be prepared to stay at the outpatient clinic all day because one to three stages (separated by 20- to 40-minute waiting periods) typically are needed to completely remove the tumor. Freezing time for the specimen depends on the size and depth of the tumor, so a large tumor with fatty tissue will require a longer freezing time. Obtain a detailed patient history to minimize complications the day of the Mohs procedure. Relevant information includes the patient’s history of previous cutaneous surgeries, ultraviolet exposure, and radiation therapy.6 Obtain a detailed medication history, including aspirin-containing products, warfarin, heparin, nonsteroidal anti-inflammatory drugs, and dietary supplements that can have anticoagulant properties (including garlic, gingko biloba, ginger, and vitamin E).6,7 Whether to stop warfarin in patients undergoing cutaneous surgery is controversial, but consult the patient’s treating physician or cardiologist to determine the patient’s risk for thromboembolic events.8 Ask the patient about any history of allergy to antibiotics, tapes, adhesives, iodine, or anesthetics such as lidocaine. Also ask about the patient’s history of keloids or hypertrophic scars. Volume 28 • Number 1 • January 2015

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What is the physician assistant’s role in Mohs micrographic surgery?



FIGURE 1. Preoperative image of a basal cell carcinoma on the

right side of the mid forehead in an older man with extensive photodamage and actinic keratosis (A). Intraoperatively, two temporary sutures were placed on each side of the surgical defect to achieve hemostasis and tissue expansion; note that the landmarks are intact for proper orientation if subsequent stages are to be performed (B). A layered linear repair was performed following the natural folds on the patient’s head to achieve an optimal aesthetic outcome postoperatively (C).

Provide patient education to patients with comorbidities such as diabetes and patients who smoke; both these conditions can impair wound healing.9 Patients may be candidates for antibiotic prophylaxis if they have extensive inflammatory skin disease or are undergoing procedures on the lower extremities or groin, wedge excisions of the lip or ear, skin flaps on the nose, or skin grafts.10 Take photographs before a Mohs procedure, to document the exact tumor location and possible preexisting cosmetic and functional deficits. This is an opportune time to address any unrealistic aesthetic outcomes the patient may be expecting after Mohs surgery. A trained histotechnician who can mount, freeze, and section histology specimens “en face” is essential for the Mohs procedure, although in some cases, the Mohs surgeon or Mohs PA can substitute. While the histotechnician prepares the slides, the Mohs surgeon and Mohs PA can attend to other patients. DAY OF THE PROCEDURE Each member of the team—the patient, Mohs surgeon, Mohs PA, medical assistant, and histotechnician—should be aware of his or her role. Review the information given to the patient at the consultation and alleviate the patient’s presurgical anxiety if needed. Take photographs and measure the lesion(s) before, during, and after the procedure, and document these in the patient’s medical record (Figure 1). Use at least two examination rooms for procedures to keep up with the patient load. Because Mohs surgery involves multiple steps, having several rooms available for patients at different stages of surgery increases efficiency. JAAPA Journal of the American Academy of Physician Assistants


For instance, you can administer lidocaine with epinephrine, to two to three patients in different rooms. By the time you return to the first room, the patient will be optimally anesthetized and will have less bleeding during surgery. Obtain informed consent from the patient before surgery starts. Next, obtain and document the patient’s vital signs. If the patient’s BP and pulse are not within normal limits, delay or reschedule the procedure. If the patient is cleared for surgery, properly position him or her, prep the tumor and surrounding areas with povidone-iodine or chlorhexidine, and drape the surgical area. After properly identifying the lesion using pictures, landmarks, and triangulation when available, mark the clinical margins properly. This step—properly marking the clinical margins of different tumors—often needs to be coordinated with the Mohs surgeon to achieve an optimal specimen removal in the first stage of Mohs surgery. Inject a local anesthetic, usually lidocaine alone or lidocaine combined with epinephrine. To distract the patient and minimize the burning sensation and anticipation of the needle, apply local topical anesthetics such as lidocaine cream, pinch the surrounding area to be treated, use cold compresses, or ask the patient to squeeze a ball or the assistant’s hand. Buffering lidocaine with sodium bicarbonate is another technique, but one that reduces the anesthetic’s shelf life. Once the specimen is surgically removed during the first Mohs stage, it is divided into pieces and carefully mapped

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to keep track of the orientation (for example, by tearing a notch at the top of an index card to indicate the 12 o’clock position). Mapping the orientation lets the Mohs surgeon pinpoint the exact location of any remaining tumor when the specimen is embedded onto the slides. A 1- to 3-mm margin of clinically normal skin is taken around obvious tumors to be treated in each stage. Use the map accurately (draw the actual size of lesion and location); the Mohs surgeon will mark the positive tumor on the map, and can focus on the areas of tumor during the second stage. Some Mohs surgeons may allow PAs to perform certain aspects of intraoperative repair, such as designing a surgical repair plan, dermal suturing, epidermal suturing, flap repairs, and graft repairs.1,11 After controlling the bleeding from the created defect, place a temporary dressing and send the patient to the waiting room. If needed, temporary sutures or partial closure of the defect could be performed; be sure not to change the landmarks for proper orientation if subsequent stages are to be performed. If office space allows, establish a special waiting room for Mohs surgery patients separate from other general dermatology patients, but in close proximity to the surgical rooms being used. If a second stage is positive, clearly mark the sites of remaining tumor on a new map template. Immediately place the patient and his or her surgical tray in the room to be ready for the second stage. Inject additional anesthetic to ensure the patient’s comfort. In the second stage only the remaining tumor is removed. The resulting defect can be repaired immediately, allowed to heal by secondary intention, or undergo delayed reconstruction. Repair options include layered closures using absorbable and nonabsorbable sutures, local tissue rearrangement (flaps), and split- or full-thickness grafts. The choice of repair option depends on the size and location of the defect and the potential cosmetic outcome of the repair method. POST-MOHS SURGERY After the procedure, clean the area, and advise the patient to leave a pressure dressing on for at least 24 hours. Give the patient detailed written and verbal wound care instructions. Advise patients to change the dressings daily. Postoperative discomfort is usually minor, and can be managed with nonaspirin-containing analgesics, such as acetaminophen; opioids may be required in some instances (for example, in high-tension areas such as the scalp). Following up with each patient is important. Call each patient the evening of the procedure. Continue to monitor patient status for any possible infections or other complications in the week following the procedure, and update the supervising physician with any pertinent information. In our practice, the assistant makes follow-up calls the evening of the patient’s procedure, to check the patient’s condition and reiterate wound care instructions. Patients are warned that postoperative bleeding can occur, and told 26

to apply firm pressure to the site for 10 to 15 minutes to establish hemostasis. If bleeding continues, patients should return to the office or visit an urgent care facility. Depending on the type of skin cancer and size of the defect, patients will need to follow up with the Mohs surgeon or referring physician. Postoperative complications include hypertrophic or keloid scarring, flap tip necrosis, and partial graft sloughs that may require further intervention from the Mohs surgeon.12 Depending on the location and type of repair performed, follow up with patients 1 to 2 weeks postoperatively to ensure the surgery site is healing properly and also to remove any superficial sutures. During this visit, tell patients that the surgical site will continue to improve gradually and some healing will continue after suture removal. The wound typically will be fully healed at 6 to 12 months. Advise an additional follow-up within 6 months of Mohs surgery for a full skin examination, with yearly examinations thereafter. CONCLUSION This brief guide to Mohs surgery may help beginning Mohs PAs become more confident in their abilities, so they can help patients who need this type of surgery. JAAPA REFERENCES 1. Hyde MA, Hadley ML, Roberson C, et al. Use of physician assistants in Mohs micrographic surgery: a survey of fellowshiptrained Mohs micrographic surgeons. Dermatol Surg. 2010; 36(11):1700-1703. 2. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010;146(3):283-287. 3. American Cancer Society. Cancer Facts & Figures 2014. http:// webcontent/acspc-042151.pdf. Accessed October 24, 2014. 4. Terushkin V, Wang SQ. Mohs surgery for basal cell carcinoma assisted by dermoscopy: report of two cases. Dermatol Surg. 2009;35(12):2031-2035. 5. Asgari MM, Olson JM, Alam M. Needs assessment for Mohs micrographic surgery. Dermatol Clin. 2012;30(1):167-175. 6. Collins SC, Dufresne RG Jr. Dietary supplements in the setting of Mohs surgery. Dermatol Surg. 2002;28(6):447-452. 7. Dinehart SM, Henry L. Dietary supplements: altered coagulation and effects on bruising. Dermatol Surg. 2005;31(7 Pt 2):819-826. 8. Alam M, Goldberg LH. Serious adverse vascular events associated with perioperative interruption of antiplatelet and anticoagulant therapy. Dermatol Surg. 2002;28(11):992-998. 9. Usatine RP, Krejci-Manwaring J. Preoperative preparation. In: Usatine RP, Pfenninger JL, Stulberg DL, Small R, eds. Dermatologic and Cosmetic Procedures in Office Practice. Philadelphia, PA: Elsevier; 2011:2-8. 10. Wright TI, Baddour LM, Berbari EF, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol. 2008;59(3):464-473. 11. Resneck JS Jr, Kimball AB. Who else is providing care in dermatology practices? Trends in the use of nonphysician clinicians. J Am Acad Dermatol. 2008;58(2):211-216. 12. Greenway HT, Maggio KL, Lane R. Mohs micrographic surgery and cutaneous oncology. In: Robinson JK, Hanke WC, Siegel DM, Fratila A, eds. Surgery of the Skin: Procedural Dermatology. 2nd ed. Philadelphia, PA: Elsevier; 2010:711-731. Volume 28 • Number 1 • January 2015

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What is the physician assistant's role in Mohs micrographic surgery?

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