Disclosures: Sobanko reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
April 15, 2020
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Patients greatly underestimate scarring before Mohs surgery for facial skin cancer

Disclosures: Sobanko reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Joseph F. Sobanko, MD
Joseph F. Sobanko

Patients with facial skin cancers appeared to have unrealistic expectations regarding scarring after Mohs micrographic surgery, according to results of prospective, cross-sectional study published in JAMA Network Open.

Surgeons, however, accurately estimated the length of most surgical scars and, therefore, can help set realistic patient expectations about scar length prior to surgery, researchers noted.

Mohs micrographic surgery is performed on skin cancers in cosmetically sensitive and functionally important areas such as the nose, eyelids and lips,” Joseph F. Sobanko, MD, director of dermatologic surgery education and associate professor of dermatology at Hospital of the University of Pennsylvania, told Healio. “As Mohs and reconstructive surgeons, our priority when speaking with [patients with skin cancer] is to counsel them on a number of relevant issues, including the risk of their skin cancer, how the Mohs technique maximizes their chance at cancer cure, how we can get the surgical site to optimally heal and any other concerns they may have.”

Scarring from surgery is a major concern of many patients, Sobanko said.

Patients with facial skin cancers appeared to have unrealistic expectations regarding scarring after Mohs micrographic surgery.

“We reassure patients that we can achieve excellent cosmetic results with our surgical technique, but there is an emphasis placed on the appropriate timeline for healing and the necessary scar length to achieve those excellent results,” he said. “Many patients are unfamiliar with the geometry behind proper wound closure, so we try to explain the reason why scars are often much longer than the original cancer that was removed.”

One of the most common reasons for litigation against dermatologists revolves around a lack of communication with patients. Previous studies have shown that patients are dissatisfied when their expectations do not match actual outcomes. Setting realistic expectations about scarring after surgery for facial skin cancers, particularly after Mohs micrographic surgery, could increase patient satisfaction and decrease risk for litigation, researchers wrote.

To that end, Sobanko and colleagues compared preoperative estimates of scar length by 101 patients (56.4% men; 56.4% aged 65 years or older) and 86 surgeons with actual scar length after Mohs micrographic surgery for facial skin cancers.

Median postoperative scar length was 47 mm (interquartile range [IQR], 32-70).

Results showed 84 patients (83.2%) underestimated scar length. However, 67 surgeons (77.9%) correctly estimated scar length (P < .001).

The actual postoperative scar length was 2.2 (IQR, 1.5-3.6) times longer than the patients’ preoperative estimate and 1.1 (IQR, 1-1.2) times longer than the surgeons’ preoperative estimate (P < .001).

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Preoperative consultation with the surgeon, a personal history of Mohs micrographic surgery and patient-directed research about the surgery did not appear associated with improvement of patients’ estimations of scar length.

The study’s method of having patients draw scar length estimations directly on their skin has not been tested, researchers acknowledged.

“We were very interested to learn from this study that the conversations we were having with patients well before their day of surgery still were not resonating, since many continued to underestimate scar size on their day of surgery,” Sobanko said. "Our takeaway from all of this is that improvements are needed to ensure that patients have realistic expectations for reconstruction after Mohs surgery.

“The old way of doing things, including conversations and online resources, is not helping patients understand this difficult process,” he added. “Currently, we are hard at work engineering new methods for educating patients. We recently completed a peer mentorship pilot program that address many of the current counseling shortcomings. We look forward to publishing these data very soon.” – by John DeRosier

For more information:

Joseph F. Sobanko, MD, can be reached at Perelman Center for Advanced Medicine, 3400 Civic Center Blvd., Suite 1-330S, Philadelphia, PA 19104; email: joseph.sobanko@pennmedicine.upenn.edu.

Disclosures: Sobanko reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.