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Mohs Surgery Introduction

Mohs micrographic surgery is a specialized, in office, skin cancer surgery. It is most often performed for non-melanoma type skin cancers that meet certain size or location requirements. Mohs surgery has gained increasing popularity over the last twenty years because of its low recurrence rates and smaller surgical wounds. Fellowship trained Mohs surgeons complete a 1-2 year fellowship where they learn the diagnostic and surgical reconstructive skills necessary for such intricate work.

Mohs Technique

The advantages offered by Mohs surgery result from three essential techniques: horizontal tissue sectioning, narrow margins, and surgical mapping.

Horizontal tissue sectioning is the method by which tissue is prepared during Mohs surgery. Visible tumor is removed from the skin and transported to the lab where it is immediately frozen. Because of its inherent plasticity, the technician is able to manipulate the skin edges to lie even with the base of the specimen. The specimen is then cut horizontally, creating a transparent film that reveals the entire base and all skin edges in one layer. Traditional pathologic sectioning is performed in a vertical manner and creates only representative samples of the base . Areas between cuts are never truly examined.

The strict margin control offered by horizontal sectioning gives the Mohs surgeon the freedom to take small surgical specimens. Typical margins in conventional excisions are 5mm beyond visible tumor. In Mohs surgery, these margins are reduced to 2-3 mm.
The trade-off for small surgical specimens is a higher risk of residual tumor at the wound edge. This problem is alleviated by the use of surgical mapping techniques. When residual tumor is present, a second specimen is taken from the involved quadrant only. This process is continued until all margins are free of tumor.

Repairing the Wound

Mohs surgeons are proficient at closing complicated wounds of the face. Local tissue flaps and skin grafts are commonly used to close defects. Other methods including dermabrasion and steroid injection are employed if revision of the scar after healing is desired.

Who should have Mohs Surgery?

Mohs surgery is appropriate for skin cancers of any size on locations where the cancer tends to recur easily (central face, scalp, ears, lips, near eyes). Mohs surgery is also indicated for any skin cancers greater than 2 centimeters in size, those that arise in scars, or those subtypes of skin cancer with more aggressive nature.

Who performs the surgery?

At UTMB, Mohs surgery is performed by Dr Richard Wagner and his rotating dermatology resident. Dr Wagner is the deputy chair of the department and head of the division of dermatologic surgery. He is Mohs Fellowship trained and has over twenty years experience in the field.

What should I expect on the day of surgery?

Patients generally arrive just before 9 am. The involved area of skin is anesthetized with a small needle using lidocaine. The first stage of surgery generally takes 10-15 minutes, then a bandage is placed over the wound and the patient waits in the lounge while the skin is processed. Processing takes 1 hour, and then the tissue is examined by the surgeon using a microscope. If the margins are positive the process is repeated.
Most repairs do not begin until early afternoon. They take anywhere from 10 minutes to an hour to complete. You should expect to be in the office until 4 pm. Wound care instructions are given, and pain medicines are dispensed as needed. Scheduled follow up visits usually occur one week later.

For Residents

All dermatology residents spend 3 to 6 months (depending on class size) of their second year on the Mohs rotation. Surgeries are performed by the residents and Dr. Wagner. Senior medical students are present to assist, and Plastic surgery residents rotate through the service as well.

This gives the dermatology residents a level of exposure seen at very few programs. In the last three years, graduates have all performed over 100 cases, making them well prepared for surgical fellowships or complicated surgical procedures in their practices.

Micrographic Surgery and Dermatologic Oncology Fellowship Program

The UTMB Micrographic Surgery and Dermatologic Oncology Fellowship Program accepts one new trainee each year for a one-year fellowship. The program is fully accredited by the ACGME and is administered by the Department of Dermatology. Trainees attend conferences, act as consultants for residents and faculty and participate in the teaching of procedural dermatology to dermatology and plastic surgery residents.

Fellows acquire special competence in this subspecialty in order to pursue a career in academia or private practice. Supervision is conducted by the faculty in charge of each of the rotations the fellow undertakes. Formal rotational evaluations of the progress of the fellow is performed every three months during the fellowship and the Dermatology Clinical Competency Committee also reviews the fellow’s progress biannually in December in and in June.

The main focus of the fellowship is skin cancer diagnosis and management, with emphasis on Mohs micrographic surgery and wound reconstruction. The fellow rotates with three UTMB Mohs faculty, Dr. Richard Wagner (fellowship director) in Galveston, Dr. David Raimer (private practice, Webster), and Dr. Aaron Joseph (private practice, Pasadena). The fellow must participate in a minimum of 400 Mohs cases throughout the year and 300 reconstructions. The fellow will also rotate on the UTMB Cosmetic Dermatology Service with Dr. Erica Kelly (lasers, fillers, neurotoxins) throughout the year. The fellow also trains students and residents in procedural dermatology, presents procedural materials and interesting cases at conferences, participates in the annual resident review for procedural dermatology during ITE preparations and gives the faculty input in to the selection of the next fellow.

Applicants must have a valid, unrestricted Texas medical license in order to be considered for interview and must have completed or in the process of completing a 3 year ACGME residency in dermatology. The fellowship officially starts on July 1st of each year without exception. In addition, all Step scores are required as well as a letter of recommendation from their dermatology program director and director of Mohs surgery. UTMB will participate in the San Francisco match if there is not internal candidates selected for the fellowship position each year and UTMB decides to opt out of the match. UTMB does not permit outside residents from other institutions to rotate in the department. All applications must be complete and received by January 1st, two years prior to the commencement of the fellowship. Complete applications including proof of an unrestricted Texas Medical License for the July 1, 2018 fellowship position must be received by January 1, 2017. Suitable applicants will be invited to Galveston for a one day interview.

No moonlighting is permitted during this year long fellowship program. During the fellowship year, the fellow is required to complete at least one clinical research project that is approved by Dr. Wagner and submit it for presentation at the American College of Mohs Surgery meeting. In addition, the fellow is required to complete one quality improvement project, approved by Dr. Gibson related to Mohs surgery during the academic year.

For more information about our fellowship program and an application please contact Marianne Keeswood at 409-772-1911 or email her at makeeswo@utmb.edu.