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  • Presentation

Pearls from Complex Mohs: Difficult Tumors - The Large and Anatomically Challenging

Description

The presentation discusses advanced techniques and considerations in Mohs micrographic surgery for difficult and anatomically challenging tumors, particularly focusing on large tumors and those located in complex regions such as auricular areas and nails. Key strategies include thorough preoperative assessments to identify tumor characteristics and potential involvement of critical structures, as well as careful surgical planning to minimize complications. Techniques for specimen processing are emphasized, such as utilizing sharp dissection to debulk tumors, effectively marking and grossing large specimens, and adjusting dissection approaches to avoid false positive margins. The speaker highlights the importance of collaboration between surgeons and medical technicians to ensure successful outcomes. Special attention is given to auricular tumors due to their proximity to the facial nerve and the need for precise handling of cartilage during processing. Nail surgery is presented as both challenging and rewarding, with strategies to ensure complete excision of tumors while preserving digit integrity. The talk concludes with a focus on the importance of histologic evaluation and offers references for further reading on these techniques, inviting audience questions and interaction.

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Conclusions

  • It is essential to perform a preoperative examination to assess the tumor's characteristics, which aids in surgical planning.
  • Effective surgical planning and teamwork can minimize intraoperative stress during Mohs surgery.
  • Taking larger sections of tissue can reduce manipulation, decreasing the risk of false-positive and false-negative margin results.
  • Horizontal relaxing incisions can effectively limit false-positive margins when dealing with thick specimens.
  • A high degree of suspicion is necessary for auricular tumors, especially those near the mastoid process, due to their potential invasiveness.
  • Utilizing techniques like tragus or canalotomies can significantly improve access to auricular tumors.
  • When dealing with nail tumors, preoperative x-rays can help evaluate for bone involvement, ensuring more effective management.
  • Using Ropivacaine as an anesthetic may reduce the risk of digital ischemia and improve postoperative pain management for nail procedures.
  • Adequately marking the nail bed facilitates the complete removal of the entire nail bed for histological examination, essential for accurate diagnosis.
  • A lateral approach during dissection of nail tumors allows for easier and more effective tissue extraction.
  • Fane, Lauren S., et al. "Mohs Surgery on the Complex Contours of the Ear Optimized with Coordinated Subdivision to Isolate Sections with Single Curves." Dermatologic Surgery, vol. 49, no. 6, 6 Apr. 2023, pp. 621-623, doi:10.1097/dss.0000000000003797.
  • Goldberg, Leonard H., et al. "Nail Bed Staining as a Guide for Taking Mohs Layers of the Residual Tumors." Dermatologic Therapy, vol. 34, no. 6, 12 Oct. 2021, doi:10.1111/dth.15149.
  • Lin, Steven W., et al. "Horizontal Relaxing Incisions Limit False Positives in Thick Mohs Sections." Dermatologic Surgery, vol. 39, no. 2, Feb. 2013, pp. 189-192, doi:10.1111/dsu.12031.
  • Mori, Westley S., et al. "Mohs Micrographic Surgery at Challenging Anatomical Sites." Dermatologic Surgery, vol. 45, no. 2, Dec. 2019, doi:10.1097/dss.0000000000002255.
  • Park, Candice, et al. "How We Do It: Cartilage Releasing Incisions for Mohs Micrographic Surgery on Difficult-to-Access Tumors of the External Ear." Dermatologic Surgery, vol. 47, no. 9, 7 June 2021, pp. 1277-1278, doi:10.1111/dth.15149.
  • Roberts, F., Thum, C.K. (2021). The Conjunctival Biopsy. In: Lee's Ophthalmic Histopathology. Springer, Cham.
  • Twaij, Sara, et al. "Utilizing Tragusotomy to Optimize External Auditory Meatus Access for Mohs Micrographic Surgery: A Novel Approach." Dermatologic Surgery, vol. 47, no. 3, 13 Mar. 2020, pp. 406-408, doi:10.1097/dss.0000000000002356.
  • Zaiac, Martin N., and Eduardo Weiss. "Mohs Micrographic Surgery of the Nail Unit and Squamous Cell Carcinoma." Dermatologic Surgery, vol. 27, no. 3, Mar. 2001, pp. 246-251, doi:10.1097/00042728-200103000-00007.