American Society for Mohs Surgery (ASMS): Annual Fundamentals of Mohs Surgery

SAN DIEGO – Before he proceeds to close a wound following Mohs surgery, Dr. Howard Steinman employs the mnemonic CAT-STARTS to help him select the repair.

A modification of STARTS, Dr. Steinman uses CAT-STARTS to represent the following factors he considers prior to carrying out the repair: first assess the Cosmetic units, Areas of available skin, and Textures of available skin. Then consider closure options: Second intention and Simple (linear) repairs, Transposition flaps, Advancement flaps, Rotation flaps, Tissue interpolation flaps, and Skin grafts.

"Prior to closing, I draw in the surrounding cosmetic units of the face. Once you’ve done that, you should pay attention to the relaxed skin tension lines," Dr. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

Courtesy Dr. Howard Steinman

To illustrate, he showed attendees a digital image of a patient’s nasal lesion prior to repair. "I draw in the midline, the side of the nasal dorsum and nasal-jugal lines, and the alar fold," he explained. "Then I look at the skin texture. This case had a mix of sebaceous skin and smooth skin, so I factored that consideration in to my repair."

Candidate wounds for second-intention healing "are small, shallow wounds, usually less than 1 cm in diameter," said Dr. Steinman, who practices dermatology and Mohs surgery in Irving, Tex. "They’re usually less than a half centimeter deep. Second-intention healing is often especially effective for the alar fold and the medial canthus and less effective for the cheeks, chin, and around the lips."

If healing by second intention is not an option, "you want to consider your repair choices, from the simplest to the most complex," he said. Thus, consider simple (linear) repairs. Thereafter, his suggested order of complexity begins with transposition flaps, followed by advancement flaps, rotation flaps, tissue interpolation flaps, and skin grafts.

"The midline of the nose and the midline of the forehead are two of the best places to do linear repairs, as is the cheek and forehead," Dr. Steinman commented. "One thing to remember about straight line repairs is that they cause significant secondary motion perpendicular to the axis of closure. You need to respect that when doing linear repairs near free margins," he added.

If you unable to close a wound in a side-to-side fashion, "a transition flap may be your best option," he continued. "Because rotation flaps require longer, broad incisions, in my view you should often think about an advancement flap as your next choice after transposition flaps in terms of complexity."

Tissue interpolation flaps are reserved "for instances where no local skin flap is a better choice," he said. "The midline forehead flap is excellent for distal nasal defects because you have a broad area of skin and it’s based on a vascular pedicle. Interpolation flaps are two-stage procedures."

He views skin grafts to be a last choice for most wound repairs. "If you do them well and, when needed, laser or abrade them, they often look acceptable, but in my opinion they are the last option for many locations," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Before he proceeds to close a wound following Mohs surgery, Dr. Howard Steinman employs the mnemonic CAT-STARTS to help him select the repair.

A modification of STARTS, Dr. Steinman uses CAT-STARTS to represent the following factors he considers prior to carrying out the repair: first assess the Cosmetic units, Areas of available skin, and Textures of available skin. Then consider closure options: Second intention and Simple (linear) repairs, Transposition flaps, Advancement flaps, Rotation flaps, Tissue interpolation flaps, and Skin grafts.

"Prior to closing, I draw in the surrounding cosmetic units of the face. Once you’ve done that, you should pay attention to the relaxed skin tension lines," Dr. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

Courtesy Dr. Howard Steinman

To illustrate, he showed attendees a digital image of a patient’s nasal lesion prior to repair. "I draw in the midline, the side of the nasal dorsum and nasal-jugal lines, and the alar fold," he explained. "Then I look at the skin texture. This case had a mix of sebaceous skin and smooth skin, so I factored that consideration in to my repair."

Candidate wounds for second-intention healing "are small, shallow wounds, usually less than 1 cm in diameter," said Dr. Steinman, who practices dermatology and Mohs surgery in Irving, Tex. "They’re usually less than a half centimeter deep. Second-intention healing is often especially effective for the alar fold and the medial canthus and less effective for the cheeks, chin, and around the lips."

If healing by second intention is not an option, "you want to consider your repair choices, from the simplest to the most complex," he said. Thus, consider simple (linear) repairs. Thereafter, his suggested order of complexity begins with transposition flaps, followed by advancement flaps, rotation flaps, tissue interpolation flaps, and skin grafts.

"The midline of the nose and the midline of the forehead are two of the best places to do linear repairs, as is the cheek and forehead," Dr. Steinman commented. "One thing to remember about straight line repairs is that they cause significant secondary motion perpendicular to the axis of closure. You need to respect that when doing linear repairs near free margins," he added.

If you unable to close a wound in a side-to-side fashion, "a transition flap may be your best option," he continued. "Because rotation flaps require longer, broad incisions, in my view you should often think about an advancement flap as your next choice after transposition flaps in terms of complexity."

Tissue interpolation flaps are reserved "for instances where no local skin flap is a better choice," he said. "The midline forehead flap is excellent for distal nasal defects because you have a broad area of skin and it’s based on a vascular pedicle. Interpolation flaps are two-stage procedures."

He views skin grafts to be a last choice for most wound repairs. "If you do them well and, when needed, laser or abrade them, they often look acceptable, but in my opinion they are the last option for many locations," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Before he proceeds to close a wound following Mohs surgery, Dr. Howard Steinman employs the mnemonic CAT-STARTS to help him select the repair.

A modification of STARTS, Dr. Steinman uses CAT-STARTS to represent the following factors he considers prior to carrying out the repair: first assess the Cosmetic units, Areas of available skin, and Textures of available skin. Then consider closure options: Second intention and Simple (linear) repairs, Transposition flaps, Advancement flaps, Rotation flaps, Tissue interpolation flaps, and Skin grafts.

"Prior to closing, I draw in the surrounding cosmetic units of the face. Once you’ve done that, you should pay attention to the relaxed skin tension lines," Dr. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

Courtesy Dr. Howard Steinman

To illustrate, he showed attendees a digital image of a patient’s nasal lesion prior to repair. "I draw in the midline, the side of the nasal dorsum and nasal-jugal lines, and the alar fold," he explained. "Then I look at the skin texture. This case had a mix of sebaceous skin and smooth skin, so I factored that consideration in to my repair."

Candidate wounds for second-intention healing "are small, shallow wounds, usually less than 1 cm in diameter," said Dr. Steinman, who practices dermatology and Mohs surgery in Irving, Tex. "They’re usually less than a half centimeter deep. Second-intention healing is often especially effective for the alar fold and the medial canthus and less effective for the cheeks, chin, and around the lips."

If healing by second intention is not an option, "you want to consider your repair choices, from the simplest to the most complex," he said. Thus, consider simple (linear) repairs. Thereafter, his suggested order of complexity begins with transposition flaps, followed by advancement flaps, rotation flaps, tissue interpolation flaps, and skin grafts.

"The midline of the nose and the midline of the forehead are two of the best places to do linear repairs, as is the cheek and forehead," Dr. Steinman commented. "One thing to remember about straight line repairs is that they cause significant secondary motion perpendicular to the axis of closure. You need to respect that when doing linear repairs near free margins," he added.

If you unable to close a wound in a side-to-side fashion, "a transition flap may be your best option," he continued. "Because rotation flaps require longer, broad incisions, in my view you should often think about an advancement flap as your next choice after transposition flaps in terms of complexity."

Tissue interpolation flaps are reserved "for instances where no local skin flap is a better choice," he said. "The midline forehead flap is excellent for distal nasal defects because you have a broad area of skin and it’s based on a vascular pedicle. Interpolation flaps are two-stage procedures."

He views skin grafts to be a last choice for most wound repairs. "If you do them well and, when needed, laser or abrade them, they often look acceptable, but in my opinion they are the last option for many locations," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – When performing dermatologic surgery, "fulfilling the expectations of patients and their families is the key to satisfaction," Dr. Howard K. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

"The yin and the yang of keeping patients satisfied involves fulfilling their expectations and satisfying their unmet expectations," Dr. Steinman said. "You have to do both. The trouble is, patient expectations are often unknown, vague, or inaccurate, or they’re irrational and unachievable. These types of expectations are dangerous and often the result of significant dissatisfaction, and unfortunately, litigation and complaints to medical boards."

Examples of nonspecific expectations include remarks such as "I want to look 10 years younger," "I hate my face," "I want to look like this picture," "what do you think I need, doctor?" and "my spouse wants me to have this fixed."

In these instances, expectations need to be modified before treatment, Dr. Steinman emphasized. This is all part of the consultation.

Dr. Steinman, who practices dermatology in Irving, Tex., shared techniques that help him to stay effective, centered, and calm while satisfying patient expectations.

To track these techniques, he advised using the mnemonic AIDET, which he learned during his post as director of dermatologic and skin surgery at Scott & White Clinic in Temple, Tex. AIDET stands for acknowledge, introduce, duration, explanation, and thank you.

The "acknowledge" component of AIDET involves a visible, audible, or tactile sign acknowledging the patient’s presence and an introduction. "Every person entering the exam room or operating room should introduce themselves to the patient," Dr. Steinman said. If loved ones accompany the patient, "I’ll introduce myself to them also, and ask how they’re related. I then go on to explain my role, my background and experience, and my intention to provide excellent service."

Next, provide an estimated time frame for how long the procedure will take. For example, during Mohs surgery cases, "I’ll take the specimen out, but before I leave the room I’ll say, ‘please have a seat in the waiting room. It’s going to be about 45 minutes until your slides are ready’ – even though this usually only takes 20-25 minutes. Overestimate the time so patients don’t become disappointed."

The "explanation" component of the mnemonic is crucial, Dr. Steinman said. He makes it a point to explain what he’s going to do during the procedure and asks the patient if he or she has any questions before he starts. "If the procedure is going to hurt, let the patient know," he said. "Offer to narrate what you’re doing if the patient finds that helpful. Keep the patient informed. Explain all tasks, sounds, smells, processes, and procedures, and have your staff do the same." For example, if the procedure involves cauterizing tissue, Dr. Steinman will tell the patient, "I’m going to start cauterizing. There is going to be a bad smell. You may want to breathe through your mouth."

Finally, thank patients "for the opportunity to care for them, for their time, their patience (if they had to wait), and for choosing you," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – When performing dermatologic surgery, "fulfilling the expectations of patients and their families is the key to satisfaction," Dr. Howard K. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

"The yin and the yang of keeping patients satisfied involves fulfilling their expectations and satisfying their unmet expectations," Dr. Steinman said. "You have to do both. The trouble is, patient expectations are often unknown, vague, or inaccurate, or they’re irrational and unachievable. These types of expectations are dangerous and often the result of significant dissatisfaction, and unfortunately, litigation and complaints to medical boards."

Examples of nonspecific expectations include remarks such as "I want to look 10 years younger," "I hate my face," "I want to look like this picture," "what do you think I need, doctor?" and "my spouse wants me to have this fixed."

In these instances, expectations need to be modified before treatment, Dr. Steinman emphasized. This is all part of the consultation.

Dr. Steinman, who practices dermatology in Irving, Tex., shared techniques that help him to stay effective, centered, and calm while satisfying patient expectations.

To track these techniques, he advised using the mnemonic AIDET, which he learned during his post as director of dermatologic and skin surgery at Scott & White Clinic in Temple, Tex. AIDET stands for acknowledge, introduce, duration, explanation, and thank you.

The "acknowledge" component of AIDET involves a visible, audible, or tactile sign acknowledging the patient’s presence and an introduction. "Every person entering the exam room or operating room should introduce themselves to the patient," Dr. Steinman said. If loved ones accompany the patient, "I’ll introduce myself to them also, and ask how they’re related. I then go on to explain my role, my background and experience, and my intention to provide excellent service."

Next, provide an estimated time frame for how long the procedure will take. For example, during Mohs surgery cases, "I’ll take the specimen out, but before I leave the room I’ll say, ‘please have a seat in the waiting room. It’s going to be about 45 minutes until your slides are ready’ – even though this usually only takes 20-25 minutes. Overestimate the time so patients don’t become disappointed."

The "explanation" component of the mnemonic is crucial, Dr. Steinman said. He makes it a point to explain what he’s going to do during the procedure and asks the patient if he or she has any questions before he starts. "If the procedure is going to hurt, let the patient know," he said. "Offer to narrate what you’re doing if the patient finds that helpful. Keep the patient informed. Explain all tasks, sounds, smells, processes, and procedures, and have your staff do the same." For example, if the procedure involves cauterizing tissue, Dr. Steinman will tell the patient, "I’m going to start cauterizing. There is going to be a bad smell. You may want to breathe through your mouth."

Finally, thank patients "for the opportunity to care for them, for their time, their patience (if they had to wait), and for choosing you," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – When performing dermatologic surgery, "fulfilling the expectations of patients and their families is the key to satisfaction," Dr. Howard K. Steinman said at a meeting sponsored by the American Society for Mohs Surgery.

"The yin and the yang of keeping patients satisfied involves fulfilling their expectations and satisfying their unmet expectations," Dr. Steinman said. "You have to do both. The trouble is, patient expectations are often unknown, vague, or inaccurate, or they’re irrational and unachievable. These types of expectations are dangerous and often the result of significant dissatisfaction, and unfortunately, litigation and complaints to medical boards."

Examples of nonspecific expectations include remarks such as "I want to look 10 years younger," "I hate my face," "I want to look like this picture," "what do you think I need, doctor?" and "my spouse wants me to have this fixed."

In these instances, expectations need to be modified before treatment, Dr. Steinman emphasized. This is all part of the consultation.

Dr. Steinman, who practices dermatology in Irving, Tex., shared techniques that help him to stay effective, centered, and calm while satisfying patient expectations.

To track these techniques, he advised using the mnemonic AIDET, which he learned during his post as director of dermatologic and skin surgery at Scott & White Clinic in Temple, Tex. AIDET stands for acknowledge, introduce, duration, explanation, and thank you.

The "acknowledge" component of AIDET involves a visible, audible, or tactile sign acknowledging the patient’s presence and an introduction. "Every person entering the exam room or operating room should introduce themselves to the patient," Dr. Steinman said. If loved ones accompany the patient, "I’ll introduce myself to them also, and ask how they’re related. I then go on to explain my role, my background and experience, and my intention to provide excellent service."

Next, provide an estimated time frame for how long the procedure will take. For example, during Mohs surgery cases, "I’ll take the specimen out, but before I leave the room I’ll say, ‘please have a seat in the waiting room. It’s going to be about 45 minutes until your slides are ready’ – even though this usually only takes 20-25 minutes. Overestimate the time so patients don’t become disappointed."

The "explanation" component of the mnemonic is crucial, Dr. Steinman said. He makes it a point to explain what he’s going to do during the procedure and asks the patient if he or she has any questions before he starts. "If the procedure is going to hurt, let the patient know," he said. "Offer to narrate what you’re doing if the patient finds that helpful. Keep the patient informed. Explain all tasks, sounds, smells, processes, and procedures, and have your staff do the same." For example, if the procedure involves cauterizing tissue, Dr. Steinman will tell the patient, "I’m going to start cauterizing. There is going to be a bad smell. You may want to breathe through your mouth."

Finally, thank patients "for the opportunity to care for them, for their time, their patience (if they had to wait), and for choosing you," he said.

Dr. Steinman said that he had no relevant financial conflicts to disclose.

SAN DIEGO – If you’re thinking about adding Mohs surgery to your dermatology practice, Dr. Edward Yob recommended that you consider the following question: "Am I willing to commit the time and resources necessary to developing a Mohs practice and do it right?"

Ultimately, your decision "will be based on your experience, how efficient you are, and how interested you are in Mohs surgery," he said at the meeting sponsored by the American Society for Mohs Surgery. "There’s no dabbling in Mohs; you either do it, or you don’t."

He offered the following tips on incorporating Mohs surgery into your existing practice:

• Start small. Allow extra time, be careful in your patient selection, and avoid distractions. "You don’t want to do your first few Mohs cases when you have a very busy general dermatology clinic," advised Dr. Yob, who practices dermatology and Mohs surgery in Tulsa, Okla. "Attention to detail is the key to Mohs surgery."

• Consider the impact on your practice environment. Do you plan to generate Mohs patients from your practice, or will the cases be generated from other referring physicians? What’s your population base, what are the community practice patterns, and what’s the competition like? "Do you have a Mohs surgeon on every other block?" Dr. Yob asked. "And what’s your surgical experience and that of your team? Are you in an area where managed care is going to reimburse you?"

• Be mindful of referral sources. In 1990, when Dr. Yob moved to Oklahoma from Washington, D.C., where he served as an Air Force dermatologist, "there was not a Mohs surgeon on the Eastern side of the state," he recalled. "Primary care physicians are an enormous referral source, especially those who do simple excisions. If they know you’re there to take care of those patients, you’ll build a bond and you’ll have a steady stream of patients to care for."

Dr. Yob emphasized the importance of keeping referring physicians in the loop about the patients they send you. "If another dermatologist sends me a patient and that patient says, ‘While I’m here, do you think you could check out this spot?’ I’ll check with the referring physician first," he explained. "Some of them will say, ‘Take care of whatever the patient needs while they’re there,’ while others will say, ‘Send them back and let me do the biopsy,’ or whatever the case may be. You have to respect that. Ultimately good communication is the key."

Other potential referral sources include colleagues who specialize in the ear, nose, and throat; plastic surgery; general surgery; and ophthalmology. You can also spread the word about your practice by offering to give Mohs-specific lectures to hospital staff or to meetings of church groups or civic groups. In those cases, "emphasize the advantage of Mohs in terms of its high cure rate, the fact that it spares tissue, and the fact that it involves an immediate repair," he said.

• What will your backup support be? If a case becomes troublesome beyond your scope of expertise, can you send the patient to the hospital right away and know that he or she will be taken care of? "What about specialty backup in the form of other Mohs surgeons, or experts in pathology, ENT, plastics, radiation oncology, general surgery, neurosurgery, and urology?" he asked. "You need to be able to take advice from your backups."

• Will you use an in-house tech or a contracted tech? "If you’re only doing Mohs on a limited basis, a contracted tech works pretty well," Dr. Yob said. "How experienced is your tech? How fast are they? Are they eager to learn?"

• Be conservative with patient scheduling. Scheduling patients depends on your volume, how many rooms you have dedicated to Mohs, your surgical experience, and the experience of your team. "If you think one Mohs case will take an hour, schedule the time for 2 hours," Dr. Yob recommended. He takes a complexity-based approach to scheduling in which "1" is a minimally complex case, "2" is a moderately complex case, and "3" is a highly complex case "that is going to take you some time and is going to be tough."

Dr. Yob said that he had no relevant financial conflicts to disclose.

SAN DIEGO – If you’re thinking about adding Mohs surgery to your dermatology practice, Dr. Edward Yob recommended that you consider the following question: "Am I willing to commit the time and resources necessary to developing a Mohs practice and do it right?"

Ultimately, your decision "will be based on your experience, how efficient you are, and how interested you are in Mohs surgery," he said at the meeting sponsored by the American Society for Mohs Surgery. "There’s no dabbling in Mohs; you either do it, or you don’t."

He offered the following tips on incorporating Mohs surgery into your existing practice:

• Start small. Allow extra time, be careful in your patient selection, and avoid distractions. "You don’t want to do your first few Mohs cases when you have a very busy general dermatology clinic," advised Dr. Yob, who practices dermatology and Mohs surgery in Tulsa, Okla. "Attention to detail is the key to Mohs surgery."

• Consider the impact on your practice environment. Do you plan to generate Mohs patients from your practice, or will the cases be generated from other referring physicians? What’s your population base, what are the community practice patterns, and what’s the competition like? "Do you have a Mohs surgeon on every other block?" Dr. Yob asked. "And what’s your surgical experience and that of your team? Are you in an area where managed care is going to reimburse you?"

• Be mindful of referral sources. In 1990, when Dr. Yob moved to Oklahoma from Washington, D.C., where he served as an Air Force dermatologist, "there was not a Mohs surgeon on the Eastern side of the state," he recalled. "Primary care physicians are an enormous referral source, especially those who do simple excisions. If they know you’re there to take care of those patients, you’ll build a bond and you’ll have a steady stream of patients to care for."

Dr. Yob emphasized the importance of keeping referring physicians in the loop about the patients they send you. "If another dermatologist sends me a patient and that patient says, ‘While I’m here, do you think you could check out this spot?’ I’ll check with the referring physician first," he explained. "Some of them will say, ‘Take care of whatever the patient needs while they’re there,’ while others will say, ‘Send them back and let me do the biopsy,’ or whatever the case may be. You have to respect that. Ultimately good communication is the key."

Other potential referral sources include colleagues who specialize in the ear, nose, and throat; plastic surgery; general surgery; and ophthalmology. You can also spread the word about your practice by offering to give Mohs-specific lectures to hospital staff or to meetings of church groups or civic groups. In those cases, "emphasize the advantage of Mohs in terms of its high cure rate, the fact that it spares tissue, and the fact that it involves an immediate repair," he said.

• What will your backup support be? If a case becomes troublesome beyond your scope of expertise, can you send the patient to the hospital right away and know that he or she will be taken care of? "What about specialty backup in the form of other Mohs surgeons, or experts in pathology, ENT, plastics, radiation oncology, general surgery, neurosurgery, and urology?" he asked. "You need to be able to take advice from your backups."

• Will you use an in-house tech or a contracted tech? "If you’re only doing Mohs on a limited basis, a contracted tech works pretty well," Dr. Yob said. "How experienced is your tech? How fast are they? Are they eager to learn?"

• Be conservative with patient scheduling. Scheduling patients depends on your volume, how many rooms you have dedicated to Mohs, your surgical experience, and the experience of your team. "If you think one Mohs case will take an hour, schedule the time for 2 hours," Dr. Yob recommended. He takes a complexity-based approach to scheduling in which "1" is a minimally complex case, "2" is a moderately complex case, and "3" is a highly complex case "that is going to take you some time and is going to be tough."

Dr. Yob said that he had no relevant financial conflicts to disclose.

SAN DIEGO – If you’re thinking about adding Mohs surgery to your dermatology practice, Dr. Edward Yob recommended that you consider the following question: "Am I willing to commit the time and resources necessary to developing a Mohs practice and do it right?"

Ultimately, your decision "will be based on your experience, how efficient you are, and how interested you are in Mohs surgery," he said at the meeting sponsored by the American Society for Mohs Surgery. "There’s no dabbling in Mohs; you either do it, or you don’t."

He offered the following tips on incorporating Mohs surgery into your existing practice:

• Start small. Allow extra time, be careful in your patient selection, and avoid distractions. "You don’t want to do your first few Mohs cases when you have a very busy general dermatology clinic," advised Dr. Yob, who practices dermatology and Mohs surgery in Tulsa, Okla. "Attention to detail is the key to Mohs surgery."

• Consider the impact on your practice environment. Do you plan to generate Mohs patients from your practice, or will the cases be generated from other referring physicians? What’s your population base, what are the community practice patterns, and what’s the competition like? "Do you have a Mohs surgeon on every other block?" Dr. Yob asked. "And what’s your surgical experience and that of your team? Are you in an area where managed care is going to reimburse you?"

• Be mindful of referral sources. In 1990, when Dr. Yob moved to Oklahoma from Washington, D.C., where he served as an Air Force dermatologist, "there was not a Mohs surgeon on the Eastern side of the state," he recalled. "Primary care physicians are an enormous referral source, especially those who do simple excisions. If they know you’re there to take care of those patients, you’ll build a bond and you’ll have a steady stream of patients to care for."

Dr. Yob emphasized the importance of keeping referring physicians in the loop about the patients they send you. "If another dermatologist sends me a patient and that patient says, ‘While I’m here, do you think you could check out this spot?’ I’ll check with the referring physician first," he explained. "Some of them will say, ‘Take care of whatever the patient needs while they’re there,’ while others will say, ‘Send them back and let me do the biopsy,’ or whatever the case may be. You have to respect that. Ultimately good communication is the key."

Other potential referral sources include colleagues who specialize in the ear, nose, and throat; plastic surgery; general surgery; and ophthalmology. You can also spread the word about your practice by offering to give Mohs-specific lectures to hospital staff or to meetings of church groups or civic groups. In those cases, "emphasize the advantage of Mohs in terms of its high cure rate, the fact that it spares tissue, and the fact that it involves an immediate repair," he said.

• What will your backup support be? If a case becomes troublesome beyond your scope of expertise, can you send the patient to the hospital right away and know that he or she will be taken care of? "What about specialty backup in the form of other Mohs surgeons, or experts in pathology, ENT, plastics, radiation oncology, general surgery, neurosurgery, and urology?" he asked. "You need to be able to take advice from your backups."

• Will you use an in-house tech or a contracted tech? "If you’re only doing Mohs on a limited basis, a contracted tech works pretty well," Dr. Yob said. "How experienced is your tech? How fast are they? Are they eager to learn?"

• Be conservative with patient scheduling. Scheduling patients depends on your volume, how many rooms you have dedicated to Mohs, your surgical experience, and the experience of your team. "If you think one Mohs case will take an hour, schedule the time for 2 hours," Dr. Yob recommended. He takes a complexity-based approach to scheduling in which "1" is a minimally complex case, "2" is a moderately complex case, and "3" is a highly complex case "that is going to take you some time and is going to be tough."

Dr. Yob said that he had no relevant financial conflicts to disclose.