Mohs Micrographic Surgery for Melanoma: The Controversy and the Evidence

The speaker advocates for the use of Mohs micrographic surgery (MMS) as a primary treatment for melanoma, particularly for cases on the head and neck where standard wide local excision (WLE) is currently the recommended approach. The discussion references clinical guidelines from the AAD and NCCN, suggesting that while WLE is standard, MMS should be considered, especially in anatomically constrained areas where melanoma can have complex margins. The traditional clinical trials that established current practices mainly focused on lower-risk sites and did not adequately address the nuances of melanoma in high-risk areas like the head and neck. Statistical data presented show that MMS has lower local recurrence and higher overall survival rates compared to both staged excisions and standard WLE. Despite its advantages, the speaker highlights challenges in implementing MMS, including difficulties in pathologic interpretation, high costs, and limited reimbursement. Additionally, the necessity for greater clinician training is emphasized to improve referral rates for MMS. Overall, the speaker calls for more research to validate the benefits of MMS for melanoma and to potentially adjust existing treatment guidelines.