Solutions for Challenging Mohs Reconstructive Surgeries

Anna Bar, MD, FAAD is gearing up to present her most intriguing and challenging Mohs reconstructive surgery cases from her work at Oregon Health & Science University in Portland, OR at the 2023 American Academy of Dermatology (AAD) Annual Meeting. She is one of the panelists in the session “How Would You Reconstruct It?” on Sunday, March 19 at 1:00 pm CDT in Room 255 of the Earnest N. Morial Convention Center in New Orleans, Louisiana. Bar shared a preview of the session with Dermatology Times® Managing Editor Lauren Buchanan.

Anna Bar, MD, FAAD: My name is Dr. Anna Bar. I'm Mohs surgeon and cosmetic dermatologist at Oregon Health and Science University in Portland. And I'm also the fellowship director of the Mohs surgery fellowship.

Lauren Buchanan, MA: Anna, you're part of a session at AAD coming up called, "How Can We Reconstruct It?" And you're sharing some interesting cases from Portland, Oregon. Can you tell me a little bit about that, and what the big takeaways are from this session?

Bar: Well, this is actually a really great session that's formatted a little bit differently than many other sessions. So many sessions, you will be sitting in the audience and listening to the speaker, and they go through all their slides. And then at the end, maybe you ask some questions. But our session is very interactive. So basically, we show a case, we show a defect after Mohs surgery, and we go through about 5 different options of what people might do to reconstruct that defect, we kind of draw out the options on the photo, we show it to the audience, we have people raise their hand, say what they would do, who would do this, who would do that. So it's very interactive. And then we have a panel of experts are most surgeons, we actually have two different panels. So like the first panel does, you know a bunch of different things. The second panel will do great cases from their area. Then, it goes to the panel and the panel, just one by one, starts talking about what they would have done. You know what they have done option A, B, C, or D and why, and everyone gives their opinion on the panel. And finally, the speaker tells what they ended up doing and how it came out and often shows a video showing how to do the reconstruction. So people can pick up a lot of different pearls.

The audience is raising their hands asking questions the whole time. It's a very interactive session. We've gotten good feedback over the years from the way this session is run. I'm excited to participate in it again.

Buchanan: That's really exciting. So when it comes to Mohs surgery, obviously this is one of the most vulnerable times of a patient's life. What are some of the challenges when it comes to Mohs surgery and treating patients who have had to undergo that procedure?

Bar: Well, of course, you know, patients are often shocked at the first time they have a Mohs procedure, because, you know, sometimes we have to go in and go in twice, or maybe even three times to get the skin cancer out. I think they do come to an understanding that, you know, we're trying to keep the wound as small as possible and just only trying to take out cancerous tissue. Then, the next challenge comes when we are doing the reconstruction, because for some defects, you know, there's really only one option. Everyone's going to do it the same way, but for 80% of the things, there's probably at least three options. So, it is really interesting to hear people talk about what works in their hands, why did they choose A versus B versus C? And the patients? I don't know, if they see what goes on behind the scenes. In our heads, we often don't, you know, we don't show them I'm debating between these 3 things, but really, in our minds we are and then they make a decision. And you know, we can involve the patients really well with that step.

Sometimes presenting them with like, 5 different options, is not in the best interest of the patient is maybe best to present them with what we think are the 2 best options and ask them how's it going to fit into the lifestyle, you know, for example, some things will need a 2-stage flap or they will have to come in one additional time. But perhaps that's the best cosmetic result. So we go over that with the patient and look at their life, their pros and cons, and what they're feeling about their healing and all of those things. So, we really take the opportunity to deal with the patient. When we're in a big group of surgeons, I think we can really break it down to "We have 5 decisions here. How do we make the decision?"

Transcript has been edited for clarity