Posts Tagged mohs
Nasal Mohs Patient & The Politics of Doing The Right Thing
Posted by admin in Dr D's Truth on March 5, 2013
Recently I saw a patient with a small superficial basal cell cancer on the rim of her nose (the Nasal Ala.) She was referred by a dermatologist who had scheduled her for Mohs Surgery and wanted my help with reconstruction of the wound that would result from the Mohs surgery. I saw her before her Mohs surgery.
It is true that reconstruction in this area frequently leaves less than attractive results and that there are alternatives that might obviate her need for surgery namely topical chemotherapeutic creams. They only work for superficial disease which her biopsy indicated she had. I have used them before and they have worked pretty well but they do require a lot of follow-up visits.
At the risk of angering the local dermatologist I suggested that the patient speak with her about this possibility before her scheduled Mohs operation. It is true that that a surgeon working with his mind as opposed to with his hands makes less less money, but it is the right thing to do. The patient actually decided to have the Mohs surgery anyway.
I always wonder when I do these things if I am annoying the referring doctors and I may do so on occasion. The focus should be on what’s best for the patient, but business can distort that in some cases.
Best Regards,
John Di Saia MD
Originally posted 2010-08-23 08:00:27.
Mohs Surgery and Plastic Surgery – How Does This Work in Orange County?
Posted by admin in Dr D's Truth on March 4, 2013
Mohs surgery is surgery for the removal of skin cancer which is common in Orange County due to our “sun sitting tendencies.” It is mostly offered by dermatologists and is specifically designed to remove the cancer with a low recurrence rate. Derms generally perform it under straight local (numbing shots in the office) and it is quite profitable for them. In this case the procedure to make the hole (that is what Mohs does) pays much better than the surgery to repair that hole. Some Derms in Orange County try to use Moh’s for nearly everything as it is profitable. This is not always in the best interests of the patient.
At times a dermatologist will refer the patient to a plastic surgeon for the closure after the Mohs is complete. This can be upsetting to the patient because unless it is arranged ahead of time, the plastic surgeon may not be able to get the patient scheduled for a few days.
You may have seen people walking around with large bandages on their ears or noses. They may not have had accidents as you might have thought.
An alternative is to have the skin cancer surgery performed entirely by a plastic surgeon which can decrease the patient’s total expense and allow for anesthesia and completion of surgery in one day. The plastic surgeon may order a frozen preparation of the removed tissue in the operating room (called frozen section) and the results have a similar cure rate and often look a whole lot better. Many plastic surgeons will take cases like these as long as the cancer isn’t too small because we are paid less to remove the cancer with conventional surgery than the Derms get with Mohs.
Best Regards,
John Di Saia MD
Originally posted 2011-03-04 07:30:28.
Reader Question: Is Mohs Surgery A Gimmick?
Posted by admin in Dr D's Truth, Reader Question on November 20, 2012
Reader Question:
“I live in Florida and it seems like the dermatologists here are doing an extremely high number of Moh’s surgeries. I’m wondering if this is becoming a money making enterprise at the patients’ and insurance companies’ expense. I’m 50 y.o. and recently had a tiny crater in the corner of my nose, diagnosed as nodular BCC.
I did the Moh’s surgery, which was more invasive than I had anticipated (supposedly was very deep once they got in there) and there will be a small scar. The derm I went to does Moh’s surgery 3 days a week with at least 3 people on the table at once. She sometimes does additional ones on a 4th day. This seems to be typical of all the derms down here that do Moh’s. “
I have written about Mohs surgery here before with overtones that hint towards answering your question. Medicine in 2012 has become a group of niche markets as it is no longer a solid business strategy to just take care of people. This is sad but true. It took me years to come to this realization which has without question cost me in the big picture.
Mohs surgery is pretty profitable particularly for Dermatologists who have relatively low overhead as compared to a surgeon anyway. Many Derms local to me do them in numbers like you specify in a way that is similar. It is like an assembly line.
It is not invariably the case that when Mohs is being performed you are being fleeced, but it can be the case in some practices. Dermatologists do carefully protect their Mohs monopoly as at one point I tried to seek training in Mohs and was basically told to take a hike.
Skin cancer in the position you indicated can be difficult to cure without Mohs and deformities in that location can be difficult to repair. There is a need for Mohs, but it is totally unregulated and some practices take advantage of that to make money.
Best Regards,
John Di Saia MD
When You Really May Want A Plastic Surgeon For Skin Cancer….
Posted by admin in skin cancer on August 19, 2011
We discuss skin cancer and plastic surgery here intermittently – most recently here.
Large Basal Cell Skin Cancer Neck
Here is a case in which the gentleman had a really large skin cancer behind his neck. He of course didn’t realize it was that large. His dermatologist sent him to me before she did the removal surgery to take the skin cancer out.
After she removed the skin cancer, she sent him to me with the hole you will see after the jump (if you would like.) I operated on him the day after to perform a local flap to get this wound covered. These are not pretty cases. Many plastic surgeons avoid them as they believe that the results will impede their cosmetic practices. They may.
Obviously, this is not a cosmetic case although plastic surgery can make it look less objectionable that it would have in the hands of other specialists. If it were cosmetic, his health insurance wouldn’t have covered it. It did.
Best Regards,
John Di Saia MD
Originally posted 2009-12-31 07:30:12.
Skin Cancer Wound Repair in the OC – Not So Pretty Plastic Surgery
Posted by admin in skin cancer on July 18, 2011
The removal of large skin cancers produces large holes. This patient had Mohs surgery by a dermatologist and appears with a hole in his face from that Mohs surgery. Many people do not know that Mohs surgery is specifically to remove the cancer and has nothing to do with the closure of the wound left afterward. When the problem gets large some patients (and some dermatologists as well) request plastic surgery. This case was operated via my South Orange County office in San Clemente.
Part of plastic surgery can be the repair of otherwise more disfiguring wounds. Sometimes plastic surgery is not cosmetic.
Best Regards,
John Di Saia MD
Originally posted 2007-12-15 15:12:00.
Mohs Surgery Makes Holes Plastic Surgeons Repair – Picture Alert
Posted by admin in Dr D's Patients, Picture Warning, skin cancer on December 1, 2009
Occasionally people ask about Mohs surgery. This is a type of surgery very common in Orange County performed mostly by dermatologists removing skin cancer. Its success is operator dependent and can result in large wounds as tissue is removed progressively in an attempt to remove a cancer entirely. People with large wounds particularly in sensitive areas like the tip of the nose may want a plastic surgeon involved to help minimize deformity. The patient you see here had a skin cancer on the tip of her nose that I repaired after her Mohs surgery.
This is the “After Plastic Surgery Repair” picture.
Plastic Surgery After Moh's Fixed The Wound - 1 Month Later
Page 2 will have the after Mohs surgery and “Before and After Plastic Surgery” pictures for you. The wound picture (after just the Mohs cancer removal) is not very pretty so skip this part if you prefer.
Best Regards,
John Di Saia MD
Facial Wound Reconstruction – Picture Alert
Posted by admin in skin cancer on June 28, 2005
In a seasonal fashion, I am asked to do a whole lot more of the things that most of you don’t think of as “plastic surgery.” These include trauma and cancer cases.
Those of you with weak stomachs can simply surf away from these posts.
This gentleman came to me after visiting his dermatologist for a Mohs procedure. He had a fairly large skin cancer removed from his lip and chin. It left the ugly hole you see above on the left. I repaired his wound in the office under local (at his request). You see him three weeks later on the right. He healed very well for his years for which we were both thankful.
For those of you that would ridicule my cosmetic patients, beware that they represent the subsidy upon which my reconstructive patients receive care. I would not even pay my rent if I were living solely on your insurer’s excuse for reimbursement.
So, when you all “tee hee” about the lady who may have looked fine (to you) before her cosmetic procedure, think of people like this man. Moh’s surgery made the hole and removed the cancer. A reconstructive plastic surgeon gave him his face back.
Until Later,
John Di Saia MD
Dr D – Your Orange County Surgeon
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