Summary: Introduction and Brief History of

Mohs Micrographic Surgery in Australia and

New Zealand

•Mohsmicrographicsurgery(MMS)inAustralia and New Zealand is of utmost importance given the extreme prevalence and incidence figures for skin cancer seen in this part of the world.

•The Mohs national database has provided a fertile resource for important study of skin cancers and their outcomes.

•Repairs have been described in Australia for the very complex wounds created by surgical removal by MMS.

43.1Introduction and Brief History of Mohs Micrographic Surgery in Australia and New Zealand

Skin cancer in Australia and New Zealand is at epidemic proportions with lifelong incidences of melanoma in certain parts of Australia and New Zealand approaching 6% and nonmelanoma skin cancer approaching 50%. Point prevalence figures show over 50% of over-40-year-olds harboring actinic keratoses and 3% nonmelanoma skin cancers [1, 2].

With these alarming figures, it is no surprise that micrographic surgery in Australia and New Zealand has a rich history with the beginnings in the 1970s but really reaching maturity with dermatologists training mainly in the USA in the 1980s. Coincident with this rise was the establishment of Skin and Cancer Foundations in Australia that fostered the growth of units devoted to the provision of skin cancer services in general and micrographic surgery in particular. With great foresight a centralized data collection for Australia was established and now houses enormous databases providing a rich resource for manuscripts on the provision of surgical techniques. Training facilities were first established first in the Skin and Cancer Foundation environment and then have spread to other facilities elsewhere in Australasia. One of the foundations has used a model of patient care and registrar training which encompasses a cooperative unit of dermatologists and plastic surgeons that has contributed to a textbook on flaps in cutaneous surgery.

Manuscripts have flowed from the database, in particular describing the behaviors of tumors according to tumor site (lips, scalp) [3, 4], type [basal-cell carcinoma (BCC)], in situ and invasive squamous cell carcinoma (SCC), basosquamous and microcystic adnexal carcinoma (MAC) [5–10], and pathologic behavior (perineural invasion in BCC and SCC) [11, 12], as well as by outcome of repair options or mixtures of these parameters with a heavy emphasis by one group studying the fate of periocular skin cancer [13–18]. Mapped serial excision for melanoma has also been studied using this database [19]. The sheer weight of this prospectively organized national database has been a major contribution to the literature and our understanding of disease behavior and the place of micrographic surgery in its management.

The database findings in relation to BCC and SCC will be further expanded in Sect. 43.3. The experience has been similar to that of other countries with very high cure rates in some smaller series [20–22] independent of the database findings.

Strange presentations of uncommon tumors and strange behaviors of tumors have been the subject of some literature from Australia and New Zealand [23– 26]. The often-strange-shaped defects remaining after Mohs tumor clearances together with the confidence that these defects are likely tumor-free have fostered the development of novel methods of repair from many Mohs surgeons with Australasian practitioners being no exception. Flap designs have included repairs of simple and advanced nasal defects [27–31]. Flaps are the commonest method of MMS defects in Australia and represent some of the more challenging repairs. The use of the nasalis muscle to allow sliding-flap repair has been a commonly performed procedure in Australia and New Zealand for smaller repairs [28, 30]. For larger defects several variations of the nasolabial flap, either a modified 2-stage [29] or more recently a very novel single-stage flap repair, have emanated from this part of the world [27]. Termed the “tunneled and turned-over nasolabial flap for reconstruction of full thickness nasal ala defects,” it describes an alternative to repairing full defects of the nasal ala without requiring a second-stage revision. In this repair a donor flap is harvested from the nasolabial fold and the cheek skin above. It is a flap, which is used when the lateral alar rim is left intact but there is a substantial full thickness ala defect. It is a singlestage competitor to a two-stage nasolabial or forehead