Optimal Postoperative Follow-up After Mohs Surgery

Since its inception in the 1930s, Mohs micrographic surgery has become the standard-of-care treatment for high-risk, locally advanced non-melanoma skin cancers. It is used most often for the treatment of basal cell and squamous cell carcinomas, but often used to treat other skin lesions as well. For non-melanoma skin cancers, the cure rate with Mohs surgery is more than 90%.¹ The procedure is often performed on areas of the skin where conserving healthy tissue is important. 

The gold standard for melanoma skin cancer treatment continues to be wide local excision. However, over the last few years, Mohs surgery has been used more often in treating melanoma, especially in areas of the body where tissue sparing is desired, such as the face.²

Mohs surgery may cause a patient to experience anxiety, because the procedure is done while the patient is awake. They may also experience anxiety about the potential cosmetic outcomes following the procedure.³

Surgical Procedure

The patient does not receive general anesthesia for this surgical procedure. The affected area is cleaned and locally anesthetized. If necessary, the surgeon will debulk the lesion and remove surrounding tissue margins to ensure all the cancer is removed. The specimen is taken to the lab, cut into thin slices, and quickly frozen with inked margins, and is then reviewed under the microscope. If cancer is still present, the surgeon removes another layer of tissue only from the appropriate area. This process is repeated until all cancerous tissue has been removed with adequate margins negative for cancer. This slower surgical procedure allows for greater tissue sparing than a wide local excision. Sparing healthy tissue can allow for not only better cosmetic outcomes but also a decreased risk of local cancer recurrence.⁴ 

Mohs surgery is considered to be a safe procedure with a relatively low incidence of postoperative complications. In one study with more than 20,000 patients, the incidence of postoperative adverse events was only 0.72%. The most common adverse event was infection, followed by wound dehiscence, and bleeding. Surgeries performed on the face, legs, and scalp had higher rates of infection, and neck surgery had the greatest risk of bleeding.⁵

Postoperative Management

A study by Hafiji et al had previously demonstrated greater patient satisfaction rates when the surgeon made postoperative phone calls the evening of the surgery.⁶ These calls also allowed the surgeon to quickly identify early postoperative complications rather than relying on the patient’s ability to recognize a complication. This study suggested clinician-driven follow-up phone calls would be beneficial not only for Mohs surgery but potentially any outpatient surgery where the patient is awake. Recently, the results of a randomized clinical trial were released that focused on the optimal timing of postoperative patient phone calls after Mohs surgery.⁷ 

The objective of the study was to find the optimal timing for telephone follow-up calls, which allowed for evaluation of postoperative bleeding and pain control in addition to overall patient satisfaction. Patients were randomly assigned to 4 groups. The first group was the control arm with no follow-up phone call. The second arm received a phone call the evening of surgery; the third arm, on postoperative day 1; and the fourth on postoperative day 2.  Phone calls were made by a fellow who followed a scripted questionnaire about pain and bleeding. A patient satisfaction survey was conducted with all patients 7 to 10 days later via phone call.⁷ 

This study did not find a statistically significant difference in patient satisfaction scores in the groups that received a postoperative phone call compared with those patients who did not receive a follow-up phone call.  Patients reported higher pain levels on the evening of surgery compared with the days following surgery. Although these results do not show significantly improved patient satisfaction, phone calls made the evening of surgery may allow for better pain control in the period when the patient is experiencing the most pain. There was no statistical significance found for the timing of phone calls on bleeding events between the groups.⁷ 

References

1. Prickett KA, Ramsey ML. Mohs micrographic surgery. StatPearls [Internet]. Last update February 15, 2021. Accessed March 24, 2021. https://www.ncbi.nlm.nih.gov/books/NBK441833/
2. Beaulieu D, Fathi R, Srivastava D, Nijhawan RI. Current perspectives on Mohs micrographic surgery for melanoma. Clin Cosmet Investig Dermatol. 2018;11:309-320. doi:10.2147/CCID.S137513
3. Heller MM, Bhutani T, Lee ES, Koo J. Psychological issues regarding Mohs micrographic surgery. In: Nouri K, ed. Mohs Micrographic Surgery. Springer; 2012:549-559. 
4. Tolkachjov SN, Brodland DG, Coldiron BM, et al. Understanding Mohs micrographic surgery: a review and practical guide for the nondermatologist. Mayo Clinic Proceedings. 2017;92(8):1261-1271. doi:10.1016/j.mayocp.2017.04.009
5. Alam M, Ibrahim O, Nodzenski M, et al. Adverse events associated with Mohs microscopic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol. 2013;149(12):1378-1385. doi:10.1001/jamadermatol.2013.6255
6. Hafiji J, Salmon P, Hussain W. Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience. Br J Dermatol. 2012;167(3):570-574. doi:10.1111/j.1365-2133.2012.11011.x
7. Bednarek R, Jonak C, Golda N. Optimal timing of postoperative patient telephone calls after Mohs micrographic surgery: a randomized controlled trial. Published online July 30, 2020. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.07.106