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Optimizing the cut in Mohs' micrographic surgery in regard to skin sparing and microscopic view: is a round incision
T R Tilleman1, M M Tilleman, M H A Neumann
1Dermatology Department, Mohs' Unit, Academisch Ziekenhuis Maastricht, The Netherlands. mohs@walla.co.il
Abstract:
Saucer incision is the common cut in Mohs' micrographic surgery. To date no proof as to the superiority of this cut over other patterns has been presented. In this work we examine the round pattern aspect of the saucer incision and answer two questions: does the round cut provide the best skin-sparing pattern? And, does it provide the best microscopic view? A two-dimensional geometric analysis is used to determine whether a round incision is optimal from the standpoint of skin sparing and microscopic view. Mohs' micrographic surgery views are used to back up the geometric hypothesis. The result is that the round incision pattern is skin-wasteful compared to an incision that follows the cancerous lesion. In the lesion presented here the two cuts have a ratio of 1.5 between the two excised skin areas, indicating a waste of healthy skin of 50%. It is also shown that specimens with a pointed edge provide better layer projection. The conclusion is that a tailored cut following the lesion pattern is the optimal Mohs' incision. Therefore in the first stage of Mohs' micrographic surgery the skin cut should replicate the lesion pattern instead of a round saucer cut. Though many Mohs' surgeons already implement this philosophy, in the literature the saucer incision recommended by Dr. Frederic Mohs' remains the norm.
Insights
The standard round incision in Mohs micrographic surgery wastes 50% more skin than necessary. Tailoring incisions to the lesion shape offers superior skin sparing and microscopic visualization for better surgical outcomes.
Area of Science:
- Dermatology
- Surgical Oncology
- Geometric Analysis
Background:
- The saucer incision is the standard surgical cut in Mohs micrographic surgery.
- No prior evidence has proven the superiority of the saucer incision over other patterns.
Purpose of the Study:
- To evaluate if the round pattern of the saucer incision offers optimal skin sparing.
- To determine if the round incision provides the best microscopic view for Mohs micrographic surgery.
Main Methods:
- A two-dimensional geometric analysis was performed to assess skin sparing and microscopic view.
- Mohs micrographic surgery views were used to support the geometric findings.
Main Results:
- The round incision pattern is significantly more wasteful of healthy skin compared to lesion-following incisions.
- Excised skin areas showed a 1.5 ratio, indicating a 50% waste of healthy skin with the round cut.
- Specimens with pointed edges demonstrated improved layer projection.
Conclusions:
- A tailored incision that follows the cancerous lesion's pattern is the optimal approach for Mohs micrographic surgery.
- The standard practice of using a round saucer cut should be replaced with lesion-pattern replicating incisions in the initial stage.
- While many surgeons practice this tailored approach, the saucer incision remains the literature norm.
