flap repair. The flap is elevated and exists on a proximal pedicle near the top of the nasolabial groove and is then tunneled under the existing alar rim and folded back on itself to recreate the lining of the mucosa and the external shape. Clever use of redundancy in the flap design allows the re-formation of the alar bulk and projection.

Studied over time, there have been some changes in the practice of MMS in at least one major institution (Skin and Cancer Foundation of Australia). The major differences were a significant decrease in defect sizes and probably consequently a significant increase in the use of flap repair and side-to-side closures in 2007 as compared to more use of secondary intention wound healing and grafts being used in 1997 [32].

Summary: Work Practices of Australian Mohs

Surgeons

•Rapidly growing subspecialty in Australia

•Wide range of annual number of Mohs cases performed, averaging 201–300 cases

•98% of tumors treated located on head, neck, digits, or genitals

•90% of surgical defects reconstructed by Mohs surgeons

43.2.2 Mohs Caseload

There is considerable variability in the number of Mohs cases performed annually in Australia, with 15% performing fewer than 100 cases per year and 12% performing greater than 500 cases (Fig. 43.1), which may be explained by the practice of most Australian Mohs surgeons of blending general dermatology and Mohs surgery. Additionally, the burden of skin cancer management is shared with several other specialties, and the Mohs technique is reserved for use on highrisk tumors that are located on the head and neck, digits, or genitals in 98% of cases (Fig. 43.2). Given this careful selection for high-complexity MMS cases, following tumor removal, flap reconstructions are required most often (48%), and then direct closure (25%) and skin grafts (17%) (Fig. 43.3). Accordingly, approximately half of Australian Mohs surgeons are skilled in more-complex reconstructions such as interpolation or tunneled flaps.

43.2Work Practices of Australian Mohs Surgeons

43.2.1 Background

In January 2010 a survey was conducted among Australian Mohs surgeons so as to record demographic data, methods of practice, and annual Mohs micrographic surgery caseloads. A web link was emailed to all those registered on the Australian Mohs surgeons email list, and respondents were asked to provide estimate on various aspects of their clinical practices. Of the 39 Mohs surgeons who were sent the survey, 33 (85%) responded, revealing the greatest proportion (37%) aged 40–44 years and 90% of Mohs surgeons as male. Seventy-six percent completed their Mohs training within Australia, and in keeping with Australia’s population distribution, 88% work in an urban or suburban environment with the remaining 12% working in a rural setting.

Face 85.9%

Scalp 5.9%

Neck 4.8%

Torso 1.3%

Limbs 0.9%

Digits 0.8%

Genitals 0.3%

Fig. 43.2 Location of tumors treated with Mohs surgery