Overview of Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure
Mohs micrographic surgery, also known as MMS, is a sort of medical procedure specifically developed to remove skin cancers. The way MMS works is by allowing doctors to examine the whole outer and deeper layers of a skin tumor during the operation. This increases the chances of complete removal of the cancer, including non-melanoma skin cancers and thin melanomas – certain types of skin cancers. Furthermore, this approach also helps to preserve as much healthy tissue as possible, and it ensures that no cancer is left before moving on to repair the surgical wound.
MMS was first introduced by Dr. Frederick E. Mohs, and was initially known as chemosurgery. In the earliest form of this technique, tumors were treated with zinc chloride – a chemical compound – right where they were. After leaving it for a day, the tumor was then removed and analyzed for any remaining cancerous cells. If there was still cancer present, the process was repeated daily until no traces of cancer were left. However, this method was quite time-consuming, required multiple visits, and resulted in a damaged, necrotic – or dead – tissue at the site of removal, which made it difficult to repair the wound afterwards.
But in the 1970s, the technique was modified to what it is now. Fresh frozen section histology, a method in which the tissue is flash-frozen and then examined, was introduced. This enabled the entire procedure to be completed on the same day and without causing any damage to the wound site. As a result, wounds made during the execution of Mohs procedure can now be repaired on the same day through different methods, from simple stitching to skin grafts and flaps – moving pieces of skin to cover the wound.
Doctors who perform the Mohs procedure now usually handle the reconstruction, which is especially important for sensitive cosmetic and functional areas. The options for repairing the wound left by the Mohs procedure range from letting it heal on its own, to more complex procedures such as using local skin flaps or grafts –a piece of skin moved from one area to cover the wound. Recently, there has been a shift towards performing more intermediate closures –the intermediate level of complexity in stitching wounds, and fewer complex closures due to an update in procedural rules and definitions in 2020.
Why do People Need Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure
There are specific guidelines that help doctors decide which skin cancers can be best treated by Mohs Micrographic Surgery (a particular surgery that removes layers of cancer-containing skin), often called MMS. These guidelines, called Appropriate Use Criteria (AUC), take into account the type of cancer, how the cancer cells look under a microscope (histology), the size and location of the cancer, and specific things about the patient’s overall health, like if their immune system is weakened or if they have inherited conditions that make them more likely to get certain types of tumors.
The decision to perform an intermediate repair, a kind of surgical repair that uses layered stitching to close a wound, depends on the length and location of the wound. This repair method requires stitches in at least one deeper layer of fatty tissue beneath the skin, as well as stitches on the skin surface. An important rule to this approach is that the wound or surgical area should not be widened more than its maximum width to do the stitching.
On the other hand, complex repair is where the wound needs more attention than with an intermediate repair. The American College of Mohs Surgery defines complex repairs as those where the intermediate repair needs additional procedures. Included in this are open wounds with visible bone, cartilage, tendons, or important blood vessels and nerves. It can also involve significant cleaning of wound edges, which is often done for injuries from accidents.
Another indication for a complex repair is when the stitches must be extended farther than the maximum width of the wound. These stitches are kept along one entire edge of the wound. The wound could also be on challenging parts like the rim of the ear, the border of the lips, or the edge of the nostrils.
Sometimes, the surgeon might use a technique called retention sutures. These are special stitches made from thicker materials to lighten the load on the regular stitches. This technique can be assisted by commercially available tools that are used to protect the edges of the tissue.
Equipment used for Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure
Mohs Micrographic Surgery (MMS) is a procedure that requires a special room, equipment, and supplies to analyze tissue under a microscope. Here’s a general idea of what they use:
Scalpel handles: These are the parts the surgeon holds when using the scalpel, a surgical knife. The Bard-Parker and Beaver models are the common ones used. The Bard-Parker is slim and flat, while the Beaver is round and designed to give doctors fine control.
Blades: The scalpel blades used are often either Number (No.) 15 or No. 10. The No. 10 is a larger curved blade whose sharpest point is at its center. On the other hand, the No. 15 has a smaller design with the cutting edge near the tip, which allows for more precise control.
Forceps: Forceps are like tweezers used by surgeons. The Adson forceps have one set of teeth for handling delicate tissue. Jewler forceps are pointy and are used for manipulating smaller tissues, like skins on eyelids. DeBakey forceps have serrations, or grooves, for a better grip but could harm the wound edges. Curtis forceps have serrations and teeth, combining the benefits of handling delicate wound edges and a good grip.
Scissors: The Gradle scissors are used in Mohs surgery. These scissors are sharp and fine-tipped. Specialized dissecting Gradle scissors with black handles are used only to cut tissue, not sutures (stitches). Iris scissors are another kind of tissue scissors with sharp tips and short handles. Metzenbaum scissors have longer handles and blunt tips. Depending on the size and sharpness, this type of scissors is used for making spaces between tissues during surgery. Westcott and Castroviejo scissors are usually reserved for extremely thin skin like that of the eyelids.
Sutures: These are stitches that can be absorbable (will dissolve on their own) or non-absorbable (need to be removed).
Tissue adhesives: These are used to hold the skin together after the surgery, similar to surgical glue.
Who is needed to perform Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure ?
For more complicated surgeries, like body part repairs or rebuilds, a team is needed in the surgery room. This team usually includes the surgeon (the main doctor who does the operation), a surgical technologist (a professional trained specifically to assist in surgical operations), and at least one other assistant. These assistants often help the surgeon in important tasks during the surgery.
How is Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure performed
After the doctor has removed all the sick skin cells with Mohs micrographic surgery (MMS), the next step is to start planning how to fix the area where they have removed these cells.
Fixing the Wound
1. First, the doctor thinks about where this wound is, what body parts are near it, and which way the lines on your skin naturally run. The doctor then draws on your skin how they plan to stitch up the wound.
2. They’ll give you a local anesthetic, which is medicine that will numb the area to keep you from feeling pain. After giving the anesthetic, they clean the skin where they’ll be working and cover it with a sterile cover.
The wound can be stitched up in the middle first, and then they cut off and stitch up the extra skin that has gathered around the wound, or they can remove this extra skin first before suturing. The stitches and the extra skin should be oriented in a way to avoid pulling on or getting too close to the surrounding body parts. They should also follow the lines of the skin when possible. The skin will naturally form an oval shape that’s about three times as long as it is wide when the extra skin is cut off. On rounded parts of the body, such as the nose, more stitches would be required to prepare the skin properly. If the wound is on a curved part of the body like the forearm, the stitches can be shaped like a crescent moon or an ‘S’ to better match the shape and help the wound heal.
Sometimes, the doctor will have to cut under the skin to give the wound more room to close up, a step called undermining. Whether or not undermining is needed on a patient changes depending on the location on the body. The doctor will have to be really careful not to damage nearby blood vessels and nerves. They will stop any bleeding using electric tools and tying off the blood vessels if needed.
Stitches are a very important part of fixing wounds like this. The doctor will stitch together several layers of skin, including the skin under the visible skin as well as the surface and the skin in between. The stitches that hold together the deeper skin layers are absorbable, meaning they disappear on their own after some time. These deeper stitches are really important because they release the tension in the wound, reduce the chances of the wound reopening, and make the scar look as good as it can. The kind of stitching material used often depends on factors such as how well it knot holds, how easy it is for the doctor to use, how quickly it disappears, and how strong it is.
When it comes to absorbable stitches, there are two main types: monofilament and braided. Monofilament stitches are usually considered to have less secure knots and aren’t as easy to use, but they cause less reaction in the tissue. On the other hand, braided stitches usually are more secure and easier to handle but can cause more tissue reactivity. There’s not much scientific evidence to show if there’s a difference between these two types in how well they function and how good the cosmesis (surgical creation of normal appearance) is.
Absorbable stitches are then placed in the deep skin and dermis using a certain method that evens the wound edges. Placing certain sutures should be considered for high-tension wounds. Slipknots are also very useful for securing surgical knots in high-tension areas.
Closure
Once the wound has been prepared and the wound edges are held in position, the top layer of the wound can be stitched. The materials used to do this can be stitches that disappear on their own, or stitches that don’t disappear, staples, or tissue adhesives.
There are different ways to place these stitches. One method is called an interrupted sutures where each stitch is tied and cut off individually. This method strengthens the wound without the whole line of stitches failing if one comes apart. There is a normal method, but other types can be used to increase control of bleeding (horizontal mattress) and eversion (horizontal and vertical mattress).
Running suture allows to place stitches quicker and lessen the strangulation of tissue in a certain area. However, if one stitch breaks, the entire line of stitches could fail.
Running subcuticular suturing is another option that allows for the placement of stitches underneath the skin creating a superficial closure without the stitch going through the skin surface. This technique avoids leaving stitch marks on the surface of the skin and is cosmetically pleasing. It is most useful in low-tension wounds.
Possible Complications of Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure
There may sometimes be complications after surgeries. These can include difficulty in healing wounds, tissue dying off, scarring, changes in body shape, damage to nerves which can lead to a loss of skin sensation, excessive bleeding, formation of clotted blood under the skin called hematoma, and infections.
After a specific skin cancer surgery called Mohs micrographic surgery (MMS), complications are uncommon. The reported rate for complications is low, at half a percent. Likewise, infections at the surgery site are rare, occurring in less than 1% of cases. However, the chance of infection could vary depending on the part of the body; it’s 5% for surgeries on a leg, 2% for an arm or torso, and 1% for the head and neck.
Certain parts of the body have unique risks. For example, if an eyelid is involved, it could lead to a condition called ectropion if the surgery isn’t properly planned or if there’s tissue death. Ectropion is when the lower eyelid turns outwards away from the eye. Also, if the surgery is on the nose, it could lead to changes in the structure of the nose and cause problems with breathing.
What Else Should I Know About Mohs Micrographic Surgery Design and Execution of Intermediate and Complex Closure ?
Mohs Micrographic Surgery (MMS) is often the best treatment option for skin cancer that qualifies because it cures cancer most effectively and saves as much healthy tissue as possible. Linear repairs, a way of closing the wound after surgery, are often used after MMS. Research shows that skin doctors, or dermatologists, are usually the ones performing these repairs. Changes made in 2020 to the way closure types are reported have already made a difference in this field.
