The State of Mohs Micrographic Surgery in 2025-2026: Current Challenges, Pressures, and the Path Forward.

Abstract

Background: Mohs micrographic surgery (MMS) unites staged extirpation, comprehensive intraoperative histopathologic assessment, and immediate reconstruction to deliver durable local control with tissue conservation in anatomically critical sites. Contemporary practice, however, is shaped by intersecting forces: stewardship of indications, reimbursement trends, vertical consolidation, expanding use of intraoperative immunohistochemistry (IHC), and the emergence of complementary modalities (superficial radiation therapy; hedgehog and programmed cell death-1 [PD-1] inhibitors) alongside digital tools (teledermatology, artificial intelligence [AI], optical coherence tomography [OCT], reflectance confocal microscopy [RCM]).

Objective: To provide a narrative synthesis that clarifies where MMS adds the greatest value, delineates the appropriate roles of competing and complementary treatments, and outlines pragmatic steps (clinical, economic, and educational) to preserve high-quality, margin-controlled cutaneous oncology.

Methods: We conducted a structured narrative review of MEDLINE and Embase (January 2000-December 2025) using controlled vocabulary and keywords for MMS; basal cell and cutaneous squamous cell carcinoma; melanoma in situ; radiation therapy; systemic therapy (hedgehog/PD-1); IHC; teledermatology/AI; and optical imaging (OCT/RCM). Eligible studies included randomized trials, prospective cohorts, comparative observational studies, systematic reviews/meta-analyses, and cost or reimbursement analyses reporting local control/recurrence, complications, episode-level cost, or implementation outcomes.

Conclusion: MMS provides superior or noninferior oncologic control with tissue preservation, same-day repair, and favorable safety in ambulatory settings. Appropriate use criteria should be framed as clinical stewardship, while superficial radiation and systemic therapies are best positioned as complements to MMS when surgery is infeasible or as neoadjuvant/adjuvant strategies. Sustaining the value of MMS will require explicit documentation of surgeon work and practice expense, standardized outcomes and patient-reported measures, equitable workforce strategies, and measured adoption of validated technologies such as OCT/RCM and AI. Payers and policymakers should recognize and preserve the true clinical and economic contribution of MMS.