Mohs goes South: Micrographic surgery gaining foothold in Brazil

Key Points

International report - While the history of Mohs micrographic surgery in the United States dates back approximately 70 years, this technique is just getting started in South America, where physicians need education regarding the basics of successful Mohs surgery, says the U.S.-trained Mohs surgeon who introduced the technique in Brazil.

"Brazil is not like the United States," where every major city includes at least one Mohs surgeon, says Selma Schuartz Cernea, M.D., a Mohs surgeon at the Hospital do Servidor Público Municipal in São Paulo, Brazil.

"In Brazil, we are very few," with at most 12 to 15 dermatologists providing Mohs surgery for the country's entire population, she says. Argentina has even fewer: just two Mohs surgeons, she says.

"There was even a plastic surgeon who approached me and said he'd never seen this technique before," Dr. Cernea tells Dermatology Times.

For Mohs surgeons and aspiring Mohs surgeons, she says avoiding surgical complications demands careful preoperative planning, meticulous surgical technique and proper woundcare.

In preoperative planning, Dr. Cernea says it's important to establish whether the patient has potential comorbidities, such as hypertension, diabetes and immunosuppression. A patient's allergies and anxieties also can influence surgical outcome, she says.

Meticulous surgical technique includes good hemostasis and infection control, she says.

Technical errors also can give rise to complications, such as wound dehiscence and other problems that can create disfiguring scars, Dr. Cernea says.

Proper surgical technique begins with carefully marking the required borders, which helps pinpoint the location of stage one excision, while also facilitating the location of residual tumors.

The fresh tissue technique involves excising the tumor, including a 2 mm to 3 mm margin, and then excising a thin layer of the deep and lateral borders.

Excised tissue specimens should be uniformly thin and free of blood or concretions, she says.

"It's important to make this layer very thin, but without any holes" so that the resulting slide represents the entire spectrum of the tissue sample, Dr. Cernea says.

Technician/surgeon teamwork

"It's important for the technician to take a good cut, because if there's a problem with the cut, such as missing tissue, you may make a mistake in reading your slides," she says.

Cancer types that benefit from the Mohs technique include basal cell carcinoma (morpheaform, micronodular and metatypical), squamous cell carcinoma, dermatofibrosarcoma protuberans, microcystic adnexal carcinoma, sebaceous carcinoma and glomus tumors, Dr. Cernea says.

Because Mohs surgery is uncommon in Brazil, Dr. Cernea says she had to train her own technician, who has been working with her for four years. In this regard, she says, "You must be very patient, because it takes a while for someone to learn the proper technique."

Dr. Cernea says she introduced Mohs micrographic surgery to Brazil in 1985, after studying with several international experts over six months. These included Leonard Goldberg, M.D., Houston, Texas; Perry Robins, M.D., New York University; and Antonio Picoto, M.D., Lisbon, Portugal. In 1992, she also studied for a month with John A. Zitelli, M.D., at the University of Pittsburgh Medical Center.

She also helped to start the first academic Mohs program in Brazil, which began in 1989 at the University of São Paulo Hospital.

In 1993, Dr. Cernea became head of the Mohs Clinic at the Hospital do Servidor Público Municipal, which became a training center two years ago.

Disclosure: Dr. Cernea reports no relevant financial interests.

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