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Safety of Office-Based Mohs Surgery

There was no evidence that skin surgery needs to be pushed into the operating room.

Outpatient surgery has come under increasing criticism in the lay press, and surgical specialists and anesthesiologists in many states are pushing to regulate and limit office-based surgery. Dermatologists are especially vulnerable, as almost all of our surgery is done in the office setting. In this prospective study, the incidence of postoperative complications was evaluated in all 1052 patients with 1343 skin cancers who were treated with Mohs surgery by 1 dermatologic surgeon during a 12-month period in an academic office setting. The surgery was performed with sterile instruments, prep, and drape, but with nonsterile gloves. Repairs were done under sterile conditions. Patients stopped taking aspirin, warfarin, vitamin E, and nonsteroidal anti-inflammatory drugs in the perioperative period. Postoperative antibiotics were given to all patients undergoing flap or graft repair or repair of defects on the sebaceous skin of the nose or on the exposed perichondrium of the ear.

The overall complication rate was 1.64%. On the day of surgery, the complication rate was 0.3%: 1 patient returned to the office with hemorrhage, and 3 patients had hematomas requiring evacuation and resuturing. Delayed complications developed in 1.34% of patients: 6 cases of partial or total skin-graft necrosis, 5 cases of flap-tip necrosis, 4 cases of hematoma formation, 1 case of delayed hemorrhage, 1 case of wound dehiscence, and 1 case of wound infection. No clear causes of the complications were identified.

Comment: Mohs surgery and reconstructive surgery in the office setting using a "clean-contaminated" technique was very safe and compared favorably to skin surgery done in the operating room. Other office-based procedures that are performed under similar conditions are likely to have similarly low complication rates. These results clearly demonstrate that intrusive and expensive regulation of office-based surgery is unwarranted. Since 2000, when this study was done, our clinical practice has shifted away from prescribing postoperative antibiotics, because the benefit of these drugs, if any, is unclear (except for treating occasional ear defects). Many dermatologic surgeons no longer stop perioperative use of aspirin or warfarin, as the risk for bleeding complications is very low.

— George J. Hruza, MD

Published in Journal Watch Dermatology March 11, 2003

Citation(s):

Cook JL and Perone JB. A prospective evaluation of the incidence of complications associated with Mohs micrographic surgery. Arch Dermatol 2003 Feb; 139:143-52.

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