Surgical Insights From ACMS

Prior to ACMS 2025, 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. Dr Zitelli outlines how adhering to these core principles can enhance outcomes, especially in cosmetically sensitive areas, while preserving function and form.

Dr Zitelli is board-certified in dermatology, micrographic dermatologic surgery, and cutaneous oncology. He has been in private practice since 1987 and continues to teach students, residents, and fellows of the University of Pittsburgh Medical Center as clinical associate professor of dermatology and otolaryngology.

Transcript:

There’s 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?
A lot of it depends on what the tumor looks like before we even start. So, oftentimes, I'll walk into the room and I'll say, "Well, 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, you shouldn't even need stitches.

Other times, I can look at the wound and I'll know, very likely, what I'll have to do, and I can explain that to them. And then sometimes, you walk in and you say, "We'll take this out, and after we have all the cancer out, then you and I will talk about what kind of—how we're going to manage the wound."

Sometimes, you can let it heal if they don't want any further surgery. And a lot of times, older patients like that idea, especially if the surgery is complex.

One of the key takeaways from your session is avoiding large reconstructions for small to modest wounds. Can you share a scenario where this principle significantly improved patient recovery or satisfaction?
I think there are a few areas where it's 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.

So, with him, 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's a very 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 dermablade the wound, and then the patient can manage it and won't need a complex reconstruction like a bilobed flap or a skin graft or something like that.

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 can avoid more complex reconstructions on the ear, especially grafts.

Other places include the hair-bearing scalp. Non-hair-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's a superficial tumor—the hair will grow back because you're not going deep enough to affect that. And patients, of course, love that because you can't see a scar if the hair grows back.

What are your top technical strategies for achieving effective closure with minimal reconstruction, especially in cosmetically sensitive areas?
Part of that would be taking a layer very superficially. Now, I think one of the reasons that the fellows I train—or the fellow applicants—they come in and tell me the story like, "Wow, we don't do that at our institution. Every Mohs layer is full thickness, and all of them are repaired."

That's what stimulated me to give this talk. But you have to have a good lab. Some lab technicians are hard to train, they're 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.

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?

I think the answer to that question is: you really need a good assistant and to train them—to put proper tension on the wound while you're doing it, to know where to—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 to take it.

Or how to wipe. For example, Fred Mohs’ nurse, Rachel, was absolutely the best. She knew how to, when we're taking the layer, 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 really important both when you're taking layers and when you're doing reconstruction. That's the key.

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?
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 don't crush the skin. Skin hooks handle the skin gently. They allow you to estimate tension when you're pulling them together better than anything else.

They're a little bit hard to use in the very beginning, but every fellow that we've trained—and that's 58 or more—have 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've learned it, you never go back.

Is there anything else you’d like to share with your colleagues regarding Mohs surgery?
I just hope that everybody continues to give back. We've been given so much by learning this technique—it's so valuable. It's given us a good lifestyle, and people can give back by contributing to the fund of knowledge: by doing studies, by donating financially to the Mohs college to support research.

Because we have come so far—we are now the reconstructive surgeons for flaps, grafts, primary closures of the skin—compared to any other specialty: plastics, ear, nose, and throat, or general surgery.

And we are oncologists of the skin. We are specialists in skin cancer. And the only way that we have gotten there is because people have worked hard and contributed, shared their own knowledge and their own research.