In reply It is nice to see the correspondence and interest of Michael Alexiou, MD. He brings up several excellent points, and it is a pleasure to respond. First, the point of our study1 is to recognize that when Mohs surgery is not performed, perhaps a slightly larger margin should be obtained during primary gross excision. It does not claim that Mohs surgery is always indicated.
Dr Alexiou’s letter challenges Mohs surgery as the gold standard for skin cancer excision. To that end, I will attempt to address his points. There is no question that all surgeons are not the same in ability. Having said that, however, one must assume that we all have the patient’s best interest in mind and would like nothing more than to have the cancer completely excised at first go-round. Good lighting and loupe magnification certainly make sense, but I hope he is not insinuating that they compare with the microscope in terms of identifying tumor margins. Mohs surgeons remove skin cancer, all day, every day, for a career, and yet they still occasionally underestimate clinical tumor extent. One cannot compare the 2 techniques (Mohs surgery vs frozen section control) in terms of percentage of specimen margin that is analyzed histopathologically. Furthermore, excellent cure rates are not the only advantage of Mohs surgery. An aggressive surgical margin on all nodular basal cell carcinomas would likely diminish the recurrence rate to well less than 1%. Mohs surgery achieves high cure rates while maximizing tissue preservation, a paramount consideration on the face. With regards to time, I am not sure a routine visit to the Mohs surgeon is much longer than an operative visit in which frozen sections are being obtained, as Dr Alexiou suggests. The fact that a Mohs surgeon cannot close all cutaneous defects is not a reason to avoid them; it leads to interdisciplinary patient care. Collaboration between the primary dermatologist, Mohs surgeon, plastic surgeon, oculoplastic surgeon, and facial plastic surgeon should be the “gold standard.”