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Dismiss the Dogma and Close Mohs Surgery the Day After?

If you perform a lot of Mohs micrographic surgery in your dermatology practice, you probably close the majority of surgical wounds on the same day. 

Why? “It’s always done that way,” Dr. Andrew Weinstein said. This dogma exists, he said, because physicians who start and complete Mohs surgery on the same day are thought to be more efficient. Also, some dermatologists believe a surgical site left open overnight increases the risk for bleeding, pain, and infection.  

But these beliefs are not necessarily true, Dr. Weinstein said. 

Dr. Andrew Weinstein (photo by D. McNamara)

The serious infection rate is no different with delayed closure, Dr. Weinstein said. He reported nine infections in a series of 1,000 of his patients (0.9% rate). Eight occurred with delayed closure, but each was an uncomplicated infection. The only major infection arose in a patient closed on the same day. 

Benefits for the dermatologist include not feeling as rushed or tired after a full day of surgery. “Ease of repair is an advantage. You have a night to collect your thoughts and you can change your repair approach,” Dr. Weinstein said at the annual meeting of the Florida Society of Dermatologic Surgeons

Delayed closure and staggered scheduling allow Dr. Weinstein to perform 20% more Mohs surgeries each day. “It’s increased my efficiency.” His Mohs technician is more efficient as well, returning slides in as little as 10 minutes.

On a typical day in his private practice in Boynton Beach, Fla., Dr. Weinstein sees four patients at 1 p.m., three more at 2 p.m., and another three at 2:30 p.m. Results of the Mohs excisions for the first group are read before the second wave of patients arrive. The 1 p.m. patients with negative results go home immediately, typically within 45 minutes, he said. Patients with positive margins remain. “Then I [excise] the first stage of the second group and anything left over from first group.” The process is repeated once the third group of patients arrives as well.  

Dr. Weinstein places retention sutures postop and schedules most of his Mohs patients to return the next morning for complete wound closure. (There are still exceptions ; he closes some the same day if it is indicated.)

Although less convenient for patients, they end up waiting less time overall, Dr. Weinstein said. He has received “generally good reviews from patients,” including previous Mohs patients and new ones. 

Patients are scheduled for wound closure in 15 minute appointments the next morning. The suturing is generally done by 11:15 AM.  

Another dermatologist at the meeting asked Dr. Weinstein if his next-day approach was motivated in part by additional insurance payment. He started doing delayed closures before changes to insurance allowed him to collect more money for seeing the patient again the next day, he replied. “The reimbursement is not the reason for what I presented here today.” 

–Damian McNamara, @MedReporter on twitter

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