Precision Over Complexity: Honoring Mohs Principles in Modern Reconstruction
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He has been in private practice since 1987 and continues to teach students, residents, and fellows of the University of
Pittsburgh Medical Center as a clinical associate professor of dermatology and otolaryngology.
In this insightful discussion, John A. Zitelli, MD, FACMS, shares foundational surgical wisdom on Moh’s surgery, highlighting the value of minimalist reconstruction, ultra-thin excision layers, and patient-driven closure planning.
The Dermatologist: There is an emphasis on tailoring closures to patient desires and expectations. How do you approach this conversation preoperatively to ensure alignment between aesthetic goals and surgical outcomes?
Dr Zitelli: A lot of it depends on what the tumor looks like before we even start. Often, I will walk into the room and say, “This is your lucky day. It looks like we might be able to take care of this cancer, and you might not even need stitches.” So, if I can get it out the first time, the patient should not even need stitches. Other times, I can look at the wound and I will likely know what I will have to do, and I can explain that to the patient. And then sometimes, I walk in and say, “We will take this out, and after we have all the cancer out, then you and I will talk about how we are going to manage the wound.” Sometimes, you can let the wound heal if they do not want any further surgery. And a lot of times, older patients like that idea, especially if the surgery is complex.
The Dermatologist: One of the key takeaways from your recent American College of Mohs Surgery Annual Meeting session was avoiding large reconstructions for small to modest wounds. Can you share a scenario where this principle significantly improved patient recovery or satisfaction?
Dr Zitelli: There are a few areas where it is really important, and I think some of the younger Mohs surgeons are not being taught the way that Dr Mohs taught me or the way Dr Mohs taught a lot of people in my peer group. He would start off, when appropriate, with a very thin layer, and then the lab would process the thin layer. And like I said before, if it is a superficial wound in a certain area, you might not need stitches. Where that comes into play in my practice frequently would be on the nose, especially on the nasal tip. If I can take off a very superficial layer, we often can let that heal on its own or shave biopsy the wound, and then the patient can manage it and will not need a complex reconstruction like a bilobed flap or a skin graft. The nose is one of the most common areas where we try to take it superficially. Another area is the rim of the ear, which heals very nicely, and we can avoid more complex reconstructions on the ear, especially grafts. Other places include the hair-bearing scalp. Nonhair-bearing scalp is easy to deal with, but on hair-bearing scalp, if you take it very thin and try that in the beginning if it is a superficial tumor, the hair will grow back because you are not going deep enough to affect that. And patients, of course, love that because you cannot see a scar if the hair grows back.
The Dermatologist: What are your top technical strategies for achieving effective closure with minimal reconstruction, especially in cosmetically sensitive areas?
Dr Zitelli: Part of that would be taking a layer very superficially. Now, I think one of the reasons that stimulates me to give this talk is the fellows I train, or the fellow applicants, come in and tell me, “Wow, we do not do that at our institution. Every Mohs layer is full thickness, and all of them are repaired.” But you must have a good lab. Some lab technicians are hard to train, they are hard to find, and not every lab technician can handle a layer that is as thin as a sheet of paper, for example. So, you need a good surgeon, and you need a good lab and lab technician to be able to do that.
The Dermatologist: Hemostasis and tension control are crucial for complication avoidance. Are there any specific tools or intraoperative techniques you rely on to ensure optimal outcomes in these areas?
Dr Zitelli: I think the answer to that question is: You really need a good assistant who you train how to put proper tension on the wound and how to wipe. For example, sometimes you hit a small artery, so your assistant needs to know where to put the thumb or finger to control the bleeding so you can continue. Dr Mohs’ nurse, Rachel, was absolutely the best. She knew how to press on the wound and then slide the pressure off to the side to minimize bleeding rather than dab it and release right away. So, I think the assistant is important both when you are taking layers and when you are doing reconstruction. That is the key.
The Dermatologist: For dermatologists newer to Mohs surgery or refining their reconstructive skills, what timeless technique do you consider most underutilized but highly effective in everyday practice?
Dr Zitelli: I can tell you right off: the use of skin hooks. I think that to learn to use skin hooks during reconstructive surgery is very important. Skin hooks do not crush the skin, they handle the skin gently. They allow you to estimate tension when you are pulling them together better than anything else. They are a little bit hard to use in the beginning, but every fellow who we have trained, and that is 58 or more, has learned to use skin hooks, and they learn very quickly. In the first week or two, they are proficient, and then they never go back. Once you have learned it, you never go back.
The Dermatologist: Is there anything else you would like to share with your colleagues regarding Mohs surgery?
Dr Zitelli: I just hope that everybody continues to give back. We have been given so much by learning this technique. It is so valuable, and we can give back by contributing to the fund of knowledge by doing studies or donating financially to support research. Because we have come so far, we are now the top reconstructive surgeons for flaps, grafts, and primary closures of the skin compared to any other specialty: plastic surgery; ear, nose, and throat; or general surgery. And we are specialists in skin cancer. The only way we have gotten there is because people have worked hard and contributed, sharing their knowledge and research.
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