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Although Mohs surgery is considered a skin-sparing technique, when dealing with aggressive skin tumor that penetrates the deep tissues, the Mohs surgeon usually sacrifices uninvolved skin. We present our technique of 3D Mohs as a new concept for skin-sparing surgery. After raising a skin flap above the residual tumor, Mohs resection was performed on the deep tissues horizontally and simultaneously on the inner plan of the flap vertically. When "clear" borders were achieved, the skin flap was sutured back into place. The results show that the defect was significantly smaller, and the hair on the Mohs-treated vertical flap continue to grow, thus contributing to a more aesthetic outcome. We conclude that careful use of the 3D Mohs technique as we describe spares the healthy uninvolved skin and offers better aesthetic and functional result.

J Drugs Dermatol. 2011; 10(11): 1271-1274.

INTRODUCTION

The advantages of the Mohs technique are well documented; it allows for complete micrographic margin control, the pathology is interpreted by the surgeon himself, and thus it is more accurate and saves time and money. The defect created after the excision of the lesion is smaller, allowing for easier closure, and, if needed, immediate reconstruction.(1),(2) It has also been shown that Mohs technique for skin lesions is more cost-effective in the U.S. than conventional surgical excision.(3)

Mohs is considered a skin-sparing technique, as compared to conventional surgical excision,(4-6) but is it a truly skin-sparing surgery in all cases? Unlike breast cancer skin-sparing operations, for example, where the breast is resected while the skin envelope is preserved, in Mohs surgery the skin is excised in some instances even if it is not involved with tumor cells, just to get to a deeper layer (fascia, muscle) were tumor is still present. Still, in most cases, the immediate pathological information gathered by the surgeon allows for the surgical defect to remain as small as possible while still keeping good margin control. (7)


Every Mohs surgeon, during his years of practice, encounters skin tumors that look rather innocuous and small on the surface but extend over long distances under the skin surface.The excision of these seemingly small lesions can sometimes result in a large skin defect. This type of tumor typically appears on the forehead and scalp where the tumor, usually a morphea type BCC, finds its way to the loose areolar tissue, galea, or temporal fascia and spreads for long distances under the surface, requiring a multi-stage Mohs surgery.The dermis looks normal and in fact is not involved by the tumor, hence every new stage involves scarifying normal skin in order to get to the underlying tumor. A significantly smaller defect could have resulted if the tumor had been safely removed under the surface while maintaining the normal skin above.

We would like to suggest a new technique demonstrating how to safely extirpate such tumors while preserving the uninvolved overlying skin.

Technique

A 72-year-old male underwent a frozen section controlled extirpation of a morphea type BCC on the left side of his forehead nine years before arriving at our clinic. The post-operative defect was down to the bone and included almost all of the left half of the forehead. It was reconstructed with a radial forearm free flap.This was done under general anesthesia by a plastic surgeon, lasted nine hours and required a 12-day hospitalization. When he came to our Mohs clinic for a small BCC removal in a different location, a subcutaneous mass was noticed on the lateral border of the old free flap and a biopsy was taken. The biopsy revealed a recurrent BCC and the patient was scheduled for Mohs surgery. Upon surgery, the tumor was not yet cleared out after eight stages (Figure 1).

The surgery was halted at this stage and the patient was scheduled for another surgical session two days later. On the ninth stage of Mohs resection, the tumor was microscopically tracked spreading along the deep temporal fascia at segments number 4 and 5 (Figure 2, map 9), while the overlying skin was uninvolved. This inflicted great frustration on the surgeon, who was forced to sacrifice normal hair-bearing skin while watching a growing defect on his patient's face. During the tenth Mohs resection stage, the border was not yet completely cleared and the defect extended into the hair-bearing temporal line. At this stage the surgeon decided to conserve the normal hair-bearing skin, while still performing microscopically controlled Mohs surgery. A flap was raised around and above the still involved area. While the flap was stabilized vertically using skin hooks, a Mohs layer was taken from the involved horizontal surface (a standard Mohs layer) and another thin Mohs layer was carefully taken from under the vertical flap.The two layers were touching at the border line between the two planes (Figures 3 and 4).


After Mohs processing and histological examination of the slides, both layers were still involved with the tumor. As expected when color-coded on the Mohs maps, the involved areas on the horizontal and vertical layers were "kissing" each other, indicating that this technique is accurate (Figure 5).

During the subsequent Mohs stages, the flap was further elevated at the same plane to allow the continuation of the three-dimensional Mohs resection. Two more stages were performed this way until clear borders were finally obtained.The horizontal-vertical simultaneous Mohs maps demonstrated smaller and smaller involved "kissing" areas until "negative" result or "no tumor" was present. Thirteen Mohs stages and 62 slides were needed to complete the surgery. The vertical hair-bearing flap was placed back and secured with staples (Figure 6).

The rest of the huge defect, 10x8 cm, was reconstructed with an upward cheek advancement flap, facelift style, and a full thickness skin graft from the inner left arm.

RESULTS

The post-operative period was uneventful. Full take of the graft was observed and the hair on the Mohs-treated vertical flap continued growing (Figure 7). No tumor recurrence was observed in a six-month follow up.

DISCUSSION

Mohs surgery has long been considered the "Gold Standard" technique for the treatment of skin cancer such as BCC,(8-13) SCC(10-12) and DFSR(14) Smeets et al. concluded that Mohs is the first choice treatment for primary facial BCCs with an aggressive histopatho-logical subtype and for recurrent BCCs on the face.(9)

In recent years, the Mohs technique has been utilized more frequently in the treatment of other non-melanoma skin lesions.(15),(16) Snow et al. published their conclusions after performing Mohs surgery in nine cases of sebaceous carcinoma in the eyelid(17) and 13 cases of microcystic adnexal carcinoma.(18) Wittenberg et al. performed Mohs surgery for the treatment of five cases of eccrine porocarcinoma,(19) and Boyer et al. reviewed their experience in the treatment of 45 cases of Merkel cell carcinoma with Mohs surgery followed by radiation therapy.(20)

The advantages of the Mohs technique have been emphasized throughout the literature regarding non-melanoma skin lesions; however, it has become evident that Mohs surgery could also be used in the treatment of melanoma.(21-22) Peter et al. presented their long-term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique. They state that the use of Mohs is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible and clinical margins are poorly defined. They conclude that margin-control surgery is favored in the treatment of periocular melanoma to maximize cure rates and minimize postoperative morbidity by sparing normal tissue. (22)



The Mohs technique is basically a two-dimensional procedure. The tumor is located on the surface and the layers are removed tangentially. It seems that a three-dimensional tumor that is buried deeply under the skin cannot be cut and processed in all three dimensions, and the surgeon has to extirpate it with the overlying normal skin and proceed with a two-dimensional Mohs technique. Braun et. al has managed to create a three-dimensional reconstruction of BCC lesions using a computerized workup on Mohs slides, which enables the surgeon to follow in a better way after the full structure of the lesion.(23)Their technique allows a better understanding of the true three-dimensional structure of BCC. As such, a three-dimensional technique is required if a truly "skin sparing" surgery is to be performed.

We propose our three-dimensional (3D) Mohs technique in order to continue excising the underlying spreading tumor while keeping the upper skin surface intact, creating a lesser defect and sparing precious vital uninvolved skin. Using the 3D technique described here, normal skin can be saved and the defect is significantly smaller. Furthermore, 3D Mohs can be applied in situations were the patient has undergone a "blind" extirpation of a tumor and the defect was covered with a flap. When the pathology result indicates later on that the tumor was incompletely excised, the Mohs surgeon faces a dilemma. He has to destroy the flap in order to reach the "involved" area. Via a careful use of the 3D technique as we described -- by raising the original flap, recreating the original defect, and proceeding with 3D Mohs surgery of all the defected borders and on the undersurface of the flap -- the surgeon may save the flap and reuse it.The chances of the flap surviving are still high because it was actually delayed.(24)

The authors herby present the first 3D Mohs case and challenge other Mohs surgeons to use this logical and simple technique for selected patients. Since patients suitable for the 3D Mohs are sparse, accumulation of more data form fellows Mohs surgeons is needed to decide if this technique is valuable.





DISCLOSURES

The authors have no relevant conflicts of interest to disclose.

REFERENCES

(1.) Moehrle M, Breuninger H, Rocken M. A confusing world: What to call histology of three-dimensional tumour margins. J Eur Acad Dermatol Venereol. 2007;21 (5):591-595.

(2.) Lang PG Jr. The role of Mohs' micrographic surgery in the management of skin cancer and a perspective on the management of the surgical defect. Clin Plast Surg. 2004;31(1):5-31.

(3.) Tierney ER Hanke CW Cost effectiveness of Mohs micrographic surgery: Review of the literature. J Drugs Dermatol. 2009;8(10):914-922.

(4.) Muller FM, Dawe RS, Moseley H, Fleming CJ. Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: Tissue-sparing outcome. Dermatol Surg. 2009;35(9):1349-1354. Epub June 3, 2009.

(5.) Narayanan K, Hadid OH, Barnes EA. Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma. Cochrane Database Syst Rev. 2009;(2):CD007041.

(6.) O'Connor WJ, Lim KK, Zalla MJ, Gagnot M, Otley CC, Nguyen TH, Roenigk RK. Comparison of mohs micrographic surgery and wide excision for extramammary Paget's disease. Dermatol Surg. 2003;29(7):723-727

(7.) Lane JE, Kent DE. Surgical margins in the treatment of nonmela-noma skin cancer and mohs micrographic surgery. Curr Surg. 2005;62(5):518-526.

(8.) Schule D, Breuninger H, Schippert W, Dietz K, Moehrle M. Con-focal laser scanning microscopy in micrographic surgery (three-dimensional histology) of basal cell carcinomas. Br J Dermatol. 2009;161 (3):698-700. Epub July 2, 2009.

(9.) Smeets NW, Kuijpers Dl, Nelemans P, Ostertag JU, Verhaegh ME, Krekels GA, Neumann HA. Mohs micrographic surgery for treatment of basal cell carcinoma of the face-results of a retrospective study and review of the literature. Br J Dermatol. 2004;151(1):141-147.

(10.) Minton TJ. Contemporary Mohs surgery applications. Curr Opin Otolaryngol Head Neck Surg. 2008;16(4):376-380.

(11.) Rogers CR, Bentz ML. An evidence-based approach to the treatment of nonmelanoma facial skin malignancies. Plast Reconstr Surg. 2011; 127(2):940-948.

(12.) Cumberland L, Dana A, Liegeois N. Mohs micrographic surgery for the management of nonmelanoma skin cancers. Facial Plast Surg Clin North Am. 2009;17(3):325-335.

(13.) Dim-Jamora KC, Perone JB. Management of cutaneous tumors with mohs micrographic surgery. Semin Plast Surg. 2008;22(4):247-256.

(14.) Roh MR, Bae B, Chung KY Mohs micrographic surgery for derma-tofibrosarcoma protuberans. Clin Exp Dermatol. 2010;35< 8):849~852.

(15.) Snow SN, Madjar DD Jr. Mohs surgery in the management of cutaneous malignancies. Clin Dermatol. 2001;19(3):339-347

(16.) Nelson BR, Railan D, Cohen S. Mohs micrographic surgery for nonmelanoma skin cancers. Clin Plast Surg. 1997;24(4):705-718.

(17) Snow SN, Larson PO, Lucarelli MJ, Lemke BN, Madjar DD. Sebaceous carcinoma of the eyelids treated by mohs micrographic surgery: Report of nine cases with review of the literature. Dermatol Surg. 2002;28(7):623-631.

(18.) Snow S, Madjar DD, Hardy S, Bentz M, Lucarelli MJ, Bechard R, AughenbaughW, McFaddenX Sharata H, Dudley C, Landeck A. Mi-crocystic adnexal carcinoma: Report of 13 cases and review of the literature. Dermatol Surg. 2001;27(4):401-408.

(19.) Wittenberg GP, Robertson DB, Solomon AR, Washington CV. Eccrine porocarcinoma treated with Mohs micrographic surgery: A report of five cases. Dermatol Surg. 1999;25(11):911-913.

(20.) Boyer JD, Zitelli JA, Brodland DG, D'Angelo G. Local control of primary Merkel cell carcinoma: Review of 45 cases treated with Mohs micrographic surgery with and without adjuvant radiation. J Am Acad Dermatol. 2002;47(6):885-892.

(21.) Whalen J, Leone D. Mohs micrographic surgery for the treatment of malignant melanoma. Clin Dermatol. 2009;27(6):597-602.

(22.) Shumaker PR, Kelley B, Swann MH, Greenway HT Jr. Modified Mohs micrographic surgery for periocular melanoma and melanoma in situ:

Long-term experience at Scripps Clinic. Dermatol Surg. 2009;35(8):1263-1270. Epub May 12, 2009.

(23.) Braun RR Klumb F, Girard C, Bandon D, Salomon D, Skaria A, Adatto M, French LE, Saurat JH, Vallee JR Three-dimensional reconstruction of basal cell carcinomas. Dermatol Surg. 2005;31(5):562-566, discussion 566-568.

(24.) Myers, MB, Cherry G. Mechanism of the Delay Phenomenon. Plast Reconstr Surg. 1969:44(1 ):52-57

Isaac Zilinsky MD, (a) Perry Robins MD, (b) Alon Liran MD, (a) Oren Weissman MD, (a) Eran Millet MD, (a) Nimrod Farber MD, (a) Josef Haik MD, (a) Eyal Winkler MD (a)

(a) The Haim Sheba Medical Center, Raniat Can, Israel

(b) Professor Emeritus, New York University Medical Center, New York, NY