Practice Tips and Efficacy
Mohs Surgeons’ Favorites
by Mark Russell, MD FACMS
During their career medical professionals learn from multiple sources based on a variety of exposures including formal and informal training, conferences, independent study, and experience. Education by colleagues represents another learning resource.1 The purpose of this article is to collect favorite practice tips from our experienced colleagues. A survey addressing practice style and practice management was sent to a limited number of Mohs surgeons in private and academic practice.
I would like to thank those Mohs surgeons who were willing to share their wisdom and respond to the survey. They represent over 500 years of collective practice experience. The first of this two-part report is below.
Favorite Instrument
| John Albertini | Round handle scalpel Loupes and head lamp LaGrange scissors for harvesting Mohs layers |
| Elizabeth Billingsley | Serrated scissors for trimming skin grafts |
| Jeremy Bordeaux | Eyelid scissors Iris scissors |
| Jerry Brewer | Iris Scissors |
| David Brodland | Scalpel Skin hook |
| John Carucci | Super cut iris scissors Skin hooks |
| Jonathan Cook | 1.25x Olympus microscope objective 6" Webster needle holders from Storz/Bausch and Lomb Zimmer electric dermatome |
| Leonard Goldberg | Scissors Flexible persona blade |
| Glenn Goldman | Shea Undermining scissors Petit Halsey needle driver Rounded, knurled scalpel handle |
| Will Henghold | Single skin hook to facilitate placing subq sutures Rake-type skin hook and blunt tip Metz for undermining Siegel scalpel handle for taking Mohs layers |
| Nat Jellinek | Dual action nail nipper Gradle scissors 2.5x surgical loupes |
| Barry Leshin | Castroviejo scissors for eyelids Strabismus scissors Lagrange scissors |
| Victor Marks | Adson forceps with 0.6 or 0.8mm tip (Precise, minimal tissue damage with indirect electrocoagulation) |
| Andrew Montemarano | Castroviejo needle driver - for most facial closures Skin hooks - to not pinch tissue powder free gloves - best invention ever |
| Gary Monheit | Skin hooks #10 blade for superficial layers |
| Tri Nguyen | Surgitel 3.5x prism loupes with LED light Castroviejo needle drivers for finesse suturing Zeiss microscope with auto adjusting stage and light |
| Suzanne Olbricht | Supercuts scissors for thinning grafts Cotton tipped swabs to assist with hemostasis 4 mm curette |
| Michael Ramsey | Siegel scalpel handle Shea scissors for fine undermining Serrated curved iris scissors for cutting fatty tissue |
| Steven Rotter | Towel clamp Platform forceps |
| Tom Stasko | Skin hook for buried sutures Bishop-Harmon 1x2 forceps for gentle tissue plus use as a quill for marking with gentian violet Loupes and LED headlight |
| Allison Vidimos | 1.25 microscope objective Chalazion clamp for lips, lids and lobes Skin hooks for stabilizing wound edges during undermining |
| John Zitelli | Skin hooks CO2 laser Zitelli scissors from Tiemann |
Favorite Surgical Technique
| John Albertini | Favorite Surgical Technique Gentian violet in base of Mohs defect to ensure complete layer Frost suture to prevent ectropion Jelly roll suture for helical rim |
| Elizabeth Billingsley | Purse string Pulley stitch on scalp |
| Jeremy Bordeaux | Granny suture for deeps Running tops |
| Jerry Brewer | 3-0 PDS subcutaneous pulley suture for scalp wounds under tension |
| David Brodland | Mechanically Advantaged Suture technique Mohs surgery Bilobed flap |
| John Carucci | Rethink the closure Xenografts Granulation |
| Jonathan Cook | Nasal reconstruction with the sub-unit concept Large banner flaps to cover exposed calvarium The repair of larger full-thickness wounds of the lips with single stage procedures |
| Leonard Goldberg | STSG CLC |
| Glenn Goldman | Gentle undermining with direct visualization Ligation for hemostasis Slip knot single throw suturing |
| Will Henghold | Pulley stitch (both subq and percutaneous) Perfectly placed subq vertical mattress stitch for proper wound edge eversion Periosteal tacking stitch to avoid blunting the alar groove when advancing the cheek |
| Nat Jellinek | Bilobed/trilobed flaps Nail matrix shave biopsy Paramedian forehead flaps |
| Barry Leshin | Island pedicle/v-y advancement flaps Interpolation flaps |
| Victor Marks | Double side-by-side buried vertical mattress |
| Gary Monheit | SMAS assisted advancement facial flaps Peng flap |
| Andrew Montemarano | Deep fascial plication to reduce tension Hatchet flap for scalp wounds instead of tight primary closure Burrow's flap for small lateral & distal nasal tip wounds |
| Tri Nguyen | Interstage suture (sutures wound between stages): reduces bleeding, relaxes tension, facilitates final closure Angulating margins for larger/more aggressive cancer resection Shave harvesting for skin grafts |
| Suzanne Olbricht | Plicating sutures M-plasties Creative dog ear removal |
| Michael Ramsey | Delayed tying of deep sutures in tight spaces Drumhead graft (and sometimes drumhead with flaps) on the lateral nose Spear turnover flap in full-thickness alar defects |
| Steven Rotter | Vertical mattress |
| Tom Stasko | Pursestring suture DermaBlade for harvesting small grafts Linear closure in place of many flaps |
| Allison Vidimos | Punches through bare ear cartilage to facilitate granulation Keystone flap for leg wounds spot dermabrasion or fractionated CO2 laserabrasion to blend grafts and flaps |
| John Zitelli | Buried vertical mattress suture Periosteal suture Bilobed flap |
Favorite Cost-Saver
| John Albertini | Use of Vicryl from donor site closure for FTSG bolster rather than new silk/other suture Clean gloves for Mohs layers, not sterile Prepackaged Mohs layer trays |
| Elizabeth Billingsley | Use remaining buried suture as top suture |
| Jeremy Bordeaux | Granulation!!!!! |
| Jerry Brewer | Use same suture for plication as used for vertical mattress |
| David Brodland | Burrows triangle graft |
| John Carucci | |
| Jonathan Cook | Reusable grounding pads for electrosurgery Reusable electrocautery tips and sheaths Cross-train staff |
| Leonard Goldberg | |
| Glenn Goldman | Avoidance of general anesthesia and sedation Use of MA in lieu of RN |
| Will Henghold | Love the gentian violet and broken q-tip that I learned in fellowship; still use it to this day Proper training of staff not to be wasteful Have a solid inventory control system |
| Nat Jellinek | Appropriate first stage of Mohs surgery margins Appropriate second intention healing Debridement of dystrophic nails (no charge) |
| Barry Leshin | Customized pre-made surgical trays direct from supplier |
| Victor Marks | |
| Gary Monheit | Mix our own ALCL3 for hemostasis |
| Andrew Montemarano | Non-sterile gloves - no impact on infection rate Fast gut suture - more expensive but saves suture removal time A good office manager |
| Tri Nguyen | Definitely gentian violet and toothpick Motorola headsets for me and my staff; saves time, optimizes efficiency, saves money LED track lights; saves tens of thousands on OR lights and reinforced ceilings |
| Suzanne Olbricht | 2-inch nonsterile surgical markers Paper rulers in tear off pad Few suture choices and always consistent so wrong suture packs not opened |
| Michael Ramsey | Etch over marked lines with point of needle after numbing but before sterile scrub Take all of clinical lesion with flexible blade prior to Mohs layer Four Mohs maps (for additional layers of same lesion) on one page |
| Steven Rotter | No external sutures |
| Tom Stasko | Shop around for sutures; prices can vary 4 to 5 fold based on buying group and brand Generic oxidized cellulose (bleed stop) in place of Surgicel LED headlights in place of overhead surgical lights |
| Allison Vidimos | Running subcuticular Monocryl |
| John Zitelli | Monitor overtime by physician |
Favorite Safety Improvement
| John Albertini | Plastic sharps container dish to hold scalpel, needles on tray "Jenker" metal cylindrical holder for injection needles to prevent recapping injuries Flu vaccine provided in clinic for all staff |
| Elizabeth Billingsley | Sharps boxes on several walls |
| Jeremy Bordeaux | Suture mats for sutures that are done |
| Jerry Brewer | Pre-day huddle with surgical team |
| David Brodland | Dental roll for placement of sharps |
| John Carucci | Smoke evacuator Labeled mohs tray Photos for biopsy sites |
| Jonathan Cook | Smoke evacuators on all aspects of care Anti-fatigue mats Redundant system of checks to identify biopsy sites correctly |
| Leonard Goldberg | Needle covers post injection |
| Glenn Goldman | Sitting for surgery Anti fatigue mats Overhead exhaust fan |
| Will Henghold | We perform a surgical "time out" before every stage and repair Proper staff safety training- no substitute for that "Root cause analysis" on any safety issue that arises |
| Nat Jellinek | Use of safety syringes Allow epinephrine to sit after injection to minimize bleeding (and need for electrosurgery) Team consistency |
| Barry Leshin | Compliance with AAAHC standards |
| Victor Marks | Reverse or "palm" scalpel when moving from pt to tray to avoid inadvertent injury to nurse/assistant |
| Gary Monheit | Battery heat cautery for patient with defibrillators Mild anxiolytic medication for patients |
| Andrew Montemarano | A day off every week to avoid burnout Dental chairs and a seat for the doc to preserve posture |
| Tri Nguyen | Develop a quality improvement system that staff can initiate; hold QI meetings weekly to assess processes Turn the needle tip backwards facing the needle driver when done suturing. eliminates risk of needle injury Use QUIZLET to train staff in safety procedures and protocols; staff can use this to learn and take quizzes |
| Suzanne Olbricht | Be consistent so staff can anticipate and/or respond quickly and appropriately Pay attention to patient positioning Look at bottle every time you put in specimen label correct and specimen is IN the bottle |
| Michael Ramsey | Designated area for skin hooks and suture on tray Dye aluminum chloride with Gentian violet to avoid electrosurgery with flammable cotton applicators Pre-biopsy photos (or accurate) anatomic diagram from referring doctor prior to surgery |
| Steven Rotter | Smoke evacuator |
| Tom Stasko | Explicit instructions for MAs, residents and students on sharps handling Establishing standardized routines Photos and triangulation for lesion location |
| Allison Vidimos | Smoke evacuator attached to cautery pen Colored labels on laser goggles that match colored label on laser to ensure right eye protection Adjustable OR table |
| John Zitelli | Assessing fall risks |
References
- Sargeant J, Mann K, Sinclair D, Ferrier S, Muirhead P, van der Vleuten C, Metsemakers J. Learning in practice: experiences and perceptions of high-scoring physicians. Acad Med. 2006 Jul;81(7):655-60.