Frozen Section Mohs: A Hybrid Technique and One Plastic Surgeon\u27s Experience With 1714 Consecutive Skin Cancer Removals

Abstract

While US nonmelanoma skin cancer (NMSC) mortality rate has decreased in the past decade, its incidence is rising. Traditional surgical treatments include wide local excision, intraoperative frozen section analysis (IFSA), and Mohs micrographic surgery (MMS). IFSA and MMS are techniques that provide intraoperative analysis allowing the surgeon to confirm margins clear of malignancy and minimize tissue damage, especially in cosmetically sensitive subunits. MMS, with cure rates up to 99%-100%, is considered the gold standard but is limited geographically and financially because of specialized training. We report a hybrid surgical technique that effectively excises cutaneous malignancy but can be utilized by plastic surgeons. This hybrid technique is called frozen section Mohs (FSM), which combines both techniques utilized in IFSA and MMS. FSM is similar to IFSA in that the middle breadloaf visualizes the central deep margin but is similar to MMS in that the entire periphery is also analyzed. This paper is a retrospective review of all patients who have undergone the FSM procedure by one plastic surgeon from September 2017 to June 2023. The primary outcomes were 1) recurrence, determined by excision of skin cancer demonstrated to be arising from postexcision scar tissue, and 2) concordance between intraoperative and final pathology. There were 1714 FSM procedures performed with a cohort averaging 73.8 years old and 57% male. Zero recurrences were identified (100% cure rate). Two cases (0.11%) were false negatives and the patients returned for re-excision. About 48.2% of cases were basal cell carcinoma while 40.7% were squamous cell carcinoma. The average number of stages per FSM procedure was 1.17. The mean defect size was 1.83 cm.2 Complication rate was 2.28% (n = 39), with the most common issue being bleeding that required suturing or cautery. Our proposed FSM technique\u27s results demonstrate effective carcinoma removal comparable to MMS. Plastic surgeons may therefore utilize this technique to meet the growing demands of skin cancer surgery in the United States with equally effective outcomes