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

  1. 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.