Skin cancers

Dermatologists and plastic surgeons adopt collegial approach to Mohs

Mohs surgeons and plastic surgeons are increasingly working together on the surgical management of keratinocyte cancers to help improve patient outcomes.

According to a review of Mohs surgery conducted at The Skin Hospital in NSW between 2007 and 2017, the rates of collaboration between the two disciplines have increased over time.

The review found 2.8% of 1,426 Mohs cases in 2007 were referred to a plastic surgeon. By 2017, that rate had climbed to 13.5% of 2,482 cases.

Of the 333 cases reconstructed by plastic surgeons in 2017, 40% had originally been seen by a plastic surgeon, referred to a Mohs surgeon for tumour excision then referred back for wound closure.

Plastic surgeons were more like to refer patients with infiltrative BCCs to their Mohs colleagues than other patients.

Other patient and tumour characteristics such as age and tumour size were not significantly different between patients based on the initial treating surgeon.

“After adjusting for other variables, plastic surgeons had greater odds of referring infiltrative BCCs than nodular BCCs (OR 2.O 95% CI 1.2–3.5 P = 0.011),” the study said.

The study found ear and temple tumours in males and females were less likely to be referred to plastic surgeons for closure.

“After adjusting for age and site, and compared to the smallest tumour size, tumour size was associated with increased referral across all subgroups in the female cohort, while only the largest tumours in the male cohort.”

“Referral was significantly associated with younger age across both sexes, reaching an OR of 4.0 and 6.2 (females and males, respectively) for patients under 45 compared to patients over 75.”

The authors said a substantial increase in Mohs cases in 2017 was likely due to an expanding Mohs workforce and “increasing knowledge surrounding superior cure rates and QOL following Mohs surgery, compared to conventional excision”.

“Our findings suggest plastic surgeons are increasingly recognising the advantages of Mohs surgery for tumour excision and reducing recurrence risk when managing infiltrative tumours, and probably considering tissue sparing and QOL outcomes for younger patients and females.”

Co-author Professor Pablo Fernandez-Penas, from Westmead Hospital and the University of Sydney, told the limbic that plastic surgeons were now more prepared to refer patients for Mohs and then do the follow-up closure.

“Classically, the plastic surgeons felt that approach was not that effective but they are coming to understand that it has a value,” he said.

He acknowledged having everything done in one place by the one surgeon would appear to be more efficient for the patient however the process offered the opportunity for each surgeon to do their best for the patient in different ways.

“Reducing the amount of tissue that you remove and ensuring that the cancer doesn’t come back is a good thing. Mohs surgery is way better in terms of the tumours being completely removed.”

He said the reasons that patients with skin cancer were first presenting to plastic surgeons required some consideration.

It appeared that some patients and GPs assumed that surgical outcomes would be better with a plastic surgeon than with a dermatologist.

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