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Commentary on Indications and Outcomes of Mohs Micrographic Surgery Using a Multidisciplinary Approach.

The authors contribute a 320-case single-center retrospective study of outcomes in Mohs micrographic surgery (MMS) performed in the operating room (OR) under general anesthesia (GA) to the literature.Wang and colleagues use a team approach whereby the Mohs surgeon extirpates the tumor under GA, and the defect is subsequently reconstructed by otolaryngology facial plastics colleagues in patients unable to undergo conventional outpatient MMS. The study patients represent a unique subset of the authors’ practice and were accumulated over 10 years (e.g., mean 32 cases annually; 2–3 monthly). Indeed, most patients at the reporting institution undergo conventionalMMSwith reconstruction by theMohs surgeon. The most common reasons for ORMMS and reconstruction are neuropsychiatric comorbidities, intolerance of outpatient MMS, and extensive anticipated defect sizes. All indications aside, with increasing pressures for use of limited health care resources, the cost-effectiveness of OR MMS should be evaluated compared with routine OR-based wide local excision with frozen sections or conventional outpatient MMS as already suggested by the authors. OR MMS should be used sparingly given the likely higher treatment cost. Neuropsychiatric comorbidities are themost intuitive reason for OR MMS and reconstruction. In some patients, this may simply be an exacerbation of underlying anxiety disorders, and the patient’s experience can be augmented by benzodiazepines or other anxiolytics in the outpatient setting. Even personalized music improves patient anxiety scores in validated patient outcome surveys. However, there is no doubt that a subset of patients requires GA or heavier sedation to achieve successful MMS and reconstruction given neuropsychiatric conditions or advanced dementia. Unfortunately, many comorbidities that make outpatient surgery difficult (e.g., chronic pulmonary disease and oxygen dependence) alsomakeGA riskier. Patients with dementia benefit from having caregivers and family available, decreased amount of support staff involved, counseling and warning of the patient, and surgery in the morning (vs late afternoon). Such patients may tolerate GA poorly because it may exacerbate the underlying cognitive decline. Most patients in this study (;55%) underwent OR MMS because of extensive anticipated defects (mean defect size: 16.5 cm), many of which occurred on the nose. Large surgical resections are commonly performed in the outpatient setting without GA, and this should always remain the standard of care. In the carefully selected patient, we and others have repaired wounds up to 120 cm in the outpatient setting without complications. Large reconstructions arewellwithin the armamentarium of many Mohs surgeons. Broken down into cosmetic subunits, complex wounds can frequently be repaired in single-stage, 2-stage, and rarely 3-stage procedures (full-thickness forehead flap with intermediate cartilage grafting and flap thinning). This approach is corroborated by the reconstructive surgeons in the article by Wang and colleagues. Dermatologists perform over 4 times the number of local flaps and over 6 times the number of grafts that plastic surgeons perform with a trend demonstrating further volume increase among dermatology reconstructions. Adequate pain control may be of concern when treating large areas. Fortunately, considerable volumes of local anesthesia are safely used in cutaneous surgery, especially when diluted to 0.5% lidocaine without compromising pain control.Undeniably, the reported multidisciplinary intervention is valuable for patients requiring a microvascular free-flap repair, rib cartilage or bone graft in (sub)total rhinectomy reconstruction, or other large reconstruction after resection of a catastrophic skin cancer. In those instances, preoperative multidisciplinary planning is essential because delaying reconstruction by over 2 days has been associated with an increased risk of complications. Transferring MMS to the OR is advantageous for a subset of patients, including those with advanced neuropsychiatric diseases or large anticipated surgical defects. Although questions regarding cost-effectiveness, medicolegal risk assumption, and optimal timing and logistics remain targets for the future study, Wang and colleagues provide valuable insights into how a multidisciplinary collaboration successfully works.