Surgical practices among Mohs surgeons for medically complex and high-risk patients: a survey of American College of Mohs surgery members

Abstract

Mohs micrographic surgery (MMS) offers high cure rates and low complication risk for skin cancer. No formal guidelines exist for preoperative clearance or perioperative management of medically complex patients. We aimed to assess current practice patterns of Mohs micrographic surgeons with membership in the American College of Mohs Surgeons (ACMS) to identify practice gaps and inform future directions for expanding best practice guidelines in MMS. A 30-question survey was distributed to American College of Mohs Surgery (ACMS) members to evaluate preoperative clearance and perioperative management of high-risk patients. Descriptive statistics and chi-squared analyses were performed. Sixty-eight surgeons responded (52% single-specialty, 20% academic, 48% suburban, 40% urban). Practice characteristics did not affect responses. Although 43% responded that they do obtain preoperative clearance, 77% of those only obtain clearance 1–5 times per year, demonstrating the infrequent use of preoperative clearance in general. When utilized, preoperative clearance was most often for severe cardiovascular disease (50%), bleeding disorders (47%), or surgical complexity (40%). Primary care (71%) and cardiology (68%) were the main consultants. For patients with implantable cardiac devices, 47% used monopolar hyfrecators over bipolar forceps (32%) and electrocautery (21%). Cardiovascular disease did not affect lidocaine with epinephrine use (90%), and 54% used plain lidocaine in pregnancy, regardless of trimester. Anxiolytics were prescribed by 67% at least a few times per year, with 63% not monitoring perioperative vital signs after giving anxiolytics. Most surgeons avoided prophylactic antibiotics in solid organ transplant recipients (13% preoperative, 34% postoperative). HIV and hepatitis C testing and viral load monitoring were rarely performed. Bloodborne pathogen precautions included verbal (77%) or written (64%) communication and double gloves (40%). This survey identifies key comorbidities and approaches to management of medically complex patients, revealing variability in practice patterns among the cohort surveyed. Few sought clearances overall, reflecting the low complication rates and overall safety of MMS. Despite this, substantial heterogeneity exists for preoperative clearance and perioperative management. The findings highlight the need for further evaluation of practices and outcomes among Mohs surgeons, along with formal guidelines to standardize care in medically complex patients.