Adapting with the Pandemic: Modified Mohs Micrographic Surgery Using Rim and Deep Margin Technique

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J Clin Aesthet Dermatol. 2024;17(6):33–35.

by Marielle Jamgochian, MD; Rohan R. Shah, BA; Christopher Yeh, MD; David Kurtyka, MD, MS;
Sam Ouellette, BA; and Babar Rao, MD

Drs. Jamgochian and Rao and Ms. Ouellette are with Department of Dermatology, Rutgers Robert Wood Johnson Medical School in Piscataway, New Jersey. Dr. Yeh and Mr. Shah are with Department of Dermatology, Rutgers New Jersey Medical School in Newark, New Jersey. Dr. Kurtyka is with the Thomas Jefferson Department of Dermatology and Cutaneous Biology in Philadelphia, Pennsylvania.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors have no conflicts of interest relevant to the content of this article.

ABSTRACT: The COVID-19 pandemic has changed many facets of medical care and has resulted in a rise in delayed treatments across all specialties, including cosmetic dermatology. Delayed care for squamous cell carcinomas (SCC) and basal cell carcinoma (BCC) is not only a burden for medical providers, but also confers a risk to patients, as delayed surgeries are associated with increased metastatic risk and tumor size. Mohs micrographic surgery (MMS) delayed by more than one year leads to increased risk of complications, including bleeding and impaired wound healing, especially in the elderly population. To decrease bleeding risks, we have developed a modified MMS technique known as the “rim and deep margin” technique. Here, we present additional cases using this technique to minimize bleeding and operative time for patients with an increased risk of morbidity. This technique has been used successfully in the past for large tumors and can now be used for patients who have faced delay of care, as evidenced by its success during the COVID-19 pandemic.

Keywords: Micrographic surgery, COVID-19, cutaneous oncology, basal cell carcinoma, squamous cell carcinoma, dermatologic surgery


Introduction

Delays in care due to the COVID-19 pandemic have affected 40.9 percent of adults in the United States (US), with 12 percent reporting avoidance of urgent care and 31.5 percent reporting avoidance of routine care.1 Patients have faced delayed care in all medical specialties, including dermatology. In a survey of 99 patients undergoing Mohs micrographic surgery (MMS) in June and July 2020, 20 percent (n=18/88) of patients reported that their MMS had been postponed, and 78 percent (n=14/18) of patients with postponed MMS indicated some level of anxiety during the waiting period.1 During the peak COVID-19 period, the average number of skin cancers diagnosed per month decreased compared to both the pre-COVID-19 era and the post-peak COVID-19 recovery period.2 A drastic reduction in skin biopsies and MMS between January and September 2020 created a backlog of six months, which will have implications for the downstream care of skin cancers.2

Delayed care for squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) is significantly associated with increased tumor size.3 In turn, SCC tumor size greater than 6cm (>2cm in some literature) is associated with an increased risk of metastasis. BCC recurrence risk is increased if tumor size is greater than 6mm on the head and neck and greater than 10mm on locations other than the head and neck.4 MMS delayed by more than one year is significantly associated with a doubling of surgical defect size.5 Additionally, increased tumor size may lead to increased risk of complications from MMS, including bleeding and impaired wound healing, especially in elderly patients with comorbidities or who are taking antithrombotic medications.3

MMS may confer an increased risk of bleeding because of the prolonged time between excision, staging, and closure. To decrease bleeding risks, we have developed a modified MMS technique known as the “rim and deep margin” technique, which was previously described in the literature by John et al6 (Figures 1A–B). In this surgical technique, peripheral tumor margins are marked, followed by a second outline marked 2mm away from the first. The 2mm wide tissue rim is removed along the periphery. To examine the deep margin, a deep tissue sample is taken from the base of the debulked tumor to subcutaneous tissue extending to the rim. 

Here, we present additional cases using the previously described technique to minimize bleeding and operative time for patients with an increased risk of morbidity. This technique has been used successfully in the past for large tumors. Furthermore, this technique may be useful in those whose surgeries had been delayed due to the COVID-19 pandemic.

Case series

Our case series includes a total of nine patients, with a male to female ratio of 7:2 and a mean age of 73.2 years (Table 1). Two patients were on anticoagulants, which were discontinued prior to surgery. The mean duration of treatment delay was three months and reasons for treatment delay included improper adherence to anticoagulants, staff unavailability due to COVID-19-related restrictions, and delayed approval for surgery. The rim and deep margin technique was used specifically for these patients due to their large tumors (>2cm in diameter; Figures 2A–B). The delayed care for skin cancers during the pandemic contributed to these large tumor sizes. 

Four patients displayed negative lateral and deep margins in the first stage, and another four displayed negative margins in the second stage. The remaining patient, who was from a nursing home and had delayed care, displayed a large tumor (8.0×6.0cm) with positive margins in the first stage, so the lesion was debulked, and the patient was subsequently referred for radiation. Thus, tumors were removed in an average of 1.5 stages using our modified Mohs technique. Of note, one of the patients who experienced delayed care was quadriplegic and unable to lay flat for the surgery but did not have any complications. Only one patient, who was taking an anticoagulant and had delayed care, experienced postoperative complications. These consisted of infection, for which the wound was cultured and resolved with oral antibiotics, and wound dehiscence, which healed by secondary intention. Other postoperative complications, such as excessive bleeding, hematoma formation, and flap necrosis, were not detected in the first six months in any patient.

Conclusion

Despite the increased risk of intraoperative morbidity from MMS due to the delayed care faced by patients during the COVID-19 pandemic, we propose the use of the rim and deep margin technique as an option for Mohs surgeons to minimize bleeding and operating time. Additionally, successful implementation of this technique can limit the perioperative complications common in high-risk patients with large tumors. Thus, the rim and deep margin technique has utility in certain high-risk patients undergoing MMS, and with the delays in care caused by the COVID-19 pandemic, it may warrant further implementation by Mohs surgeons. 

References

  1. Masroor S. Collateral damage of COVID-19 pandemic: delayed medical care. J Card Surg. 2020;35(6):1345–1347.
  2. Asai Y, Nguyen P, Hanna TP. Impact of the COVID-19 pandemic on skin cancer diagnosis: a population-based study. PLoS One. 2021;16(3):e0248492.
  3. Alam M, Billingsley EM, Storrs PA. Skin cancer screening is the standard of care and should be made more accessible to patients. Arch Dermatol Res. 2020;312(3):229–230.
  4. Caparrotti F, Troussier I, Ali A, Zilli T. Localized non-melanoma skin cancer: risk factors of post-surgical relapse and role of postoperative radiotherapy. Curr Treat Options Oncol. 2020;21(12):97.
  5. Eide MJ, Weinstock MA, Dufresne RG Jr., et al. Relationship of treatment delay with surgical defect size from keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma of the skin). J Invest Dermatol. 2005;124(2):308–314.
  6. John AM, Srivastava R, Francisco GM, Bhatti H, et al. Modified Mohs micrographic surgery with rim and deep margin technique. Int J Dermatol. 2020 Feb;59(2):e31–e33.  

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