All about Mohs Reconstruction

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm excited to be joined by returning guest Dr. Michael Fritz, Section Head of Facial Plastic and Microvascular Reconstructive Surgery at Cleveland Clinic. Dr. Fritz, welcome back to Head and Neck Innovations.

Michael Fritz: It's so nice to be back. It seems like I was just here just a little bit ago.

Paul Bryson: I know. Great to be back. It's great to have you back. You know, Dr. Fritz, for our new listeners or perhaps those that haven't had a chance to listen to our previous episode on osteoradionecrosis, let's start by having you share some background on yourself, where you're from, where you trained, how you've come to Cleveland Clinic.

Michael Fritz: So I grew up mostly in Solon, Ohio. Solon, a local boy. I went to Duke University for undergrad and Ohio State University for medical school. And then I was early on, sold on the Cleveland Clinic culture and people and did a six year residency, which included a research year and then did my fellowship at the University of Minnesota. And I was fortunate enough to get hired to come back here before I left. So I've been a Cleveland Clinic employee for about 26 years now. I was immediately attracted to facial plastic surgery and in particular microvascular surgery because there's just a lot of room for innovation. It's the fusion point of art in medicine and I love taking care of people with complex problems, both cosmetic and reconstructive. But, I have a certain passion for taking care of people with cancer.

Paul Bryson: Well, as you know, skin cancer is one of the most diagnosed cancers in the United States, but as you just mentioned, it's treatable even when it's difficult. Oftentimes patients have a, a whole ladder of, you know, treatable treatment options. And we often recommend patients who are diagnosed with skin cancer undergo Mohs surgery and reconstruction. And I wanted to talk with you about this today. Can you give the listener just a little bit of background on these procedures, particularly, you know, some of the great collaborations that you've made and maintained here at Cleveland Clinic over the years. And, you know, I don't know if patients are listening or what you have, but a little background on Mohs surgery in general and then, you know, maybe transition into how, you know, the skills and techniques that you have, and the team has can help patients.

Michael Fritz: Yeah, so most people listening are probably familiar with Mohs surgery, but just to kind of briefly go over the strength of it, obviously it's, it's a subspecialty fellowship training within dermatology and it's a combination of being a high-end pathologist and a surgeon at the same time. So, Mohs surgery processes tissue in a way that checks 100 percent of the skin margin. And that is to be contrasted with our traditional pathologic analysis, which is more like 5 percent of the margin. So, you get the best chance of durable cure. And because of the technique of Mohs surgery where they follow the edges that are positive, even though you might get a big defect when you see a small skin cancer, that's because you had a big cancer underneath. They take no more than needs to be taken. Our surgeons are excellent at closing most skin cancer defects, they're super talented, they do it all the time.

But I think one of the strengths of our group at the Cleveland Clinic is they don't hesitate if they think that an intraoperative solution with one of the facial plastic surgeons would give someone a better outcome. So, we get to those defects where they can't clear all the margins either because it's starting to go deep and it's uncomfortable for the patients. And in those situations, the Mohs surgeons will still read those margins, which is kind of unique at the Cleveland Clinic because, you know, let's face it on the outside, a lot of people can do a lot of small Mohs surgeries and do a lot better for themselves as opposed to trying to clear a big and complex defect. But our Mohs surgeons are passionate about, you know, the collaborative aspect and the end of care. I mean the edge of care, not the end of care. But we have this great relationship with them where we'll take on much bigger skin cancers than we'll be typically read with Mohs, and we'll do intraoperative Mohs reads with them. If they have larger defects, they send them to us to repair. And all the other ones that they're good at, they, they take care of, and they do an incredibly good job.

Paul Bryson: You know, for the patients and for referring people, what does the sort of multidisciplinary approach look like here? You, you described it, you know pretty well, but you know, when you have that patient who both teams are concerned, maybe have a larger defect, you know, what does that look like for the patient and, you know, what can, what can they expect in terms of reconstruction? Is it a single day, is it a single stage? Is it, is it as variable as skin cancer tumors can be? How do you manage a little bit of the unexpected when you have these bigger cancers?

Michael Fritz: Well, first of all, it's a kind of collaborative decision making. Our Mohs surgeons are very comfortable with taking care of large and recurrent skin cancers and keeping people comfortable in doing that in the office. The advantage of clearing a cancer in the office is its less time under anesthesia and it gives the reconstructive surgeon time to plan and discuss the stages with the patient. So, there's no surprise. But there are definitely cancers that come to the Cleveland Clinic where it's a large, recurrent, very deeply focused cancer, say in the nose or the cheek or around the eye. And there's no way the patient's going to be able to tolerate a resection in the office. And this is where we go in these surgeries together, we decide on what are the optimal margins to get this cleared relatively quickly. Because that's only part of the operation.

And we actually take the cancer out, the Mohs surgeons walk over the lab read margins. And while they're doing that, we're getting the spare parts we need to fix things. And when the cancer defects become bigger, it often involves things like regional flaps or free tissue transfer free flaps surgery, which we do a great deal of here. And, and in those instances, you often need structure. So, you'll need cartilage, you'll need bone, especially in the case of nasal reconstruction and ear reconstruction. And so, we get the things that are going to make the reconstruction work without disturbing the margins. Because we have to wait until they're clear. So, we can actually plug in, for instance, the free flap and get rib cartilage and not disturb any of the margins. And then make sure that it's clear and then, and then move on. So, we have this really good kind of tap-dancing word do where we're, we're filling the time that the most surgeons are as quickly as they can reading these margins and, and getting folks optimized for reconstruction.

The great thing I think about our group is we can take care of just about anything. You know, we rebuild the largest and most complicated cancer defects. We're super proficient with free tissue transfer with high success rates. So, if you all of a sudden have a total nose defect, well we're the place that does that. You know, so we're okay with taking care of the hard stuff and the recurrent cancers. And that's, I think, where our strength is. That goes beyond, there are plenty of great Mohs surgeons and plenty of great Mohs reconstructive folks, but when you want still the best margin clearance with the biggest cancers and the most kind of careful and experienced reconstruction, I think we rival just about anybody.

Paul Bryson: Well, I appreciate that. So, Mike, walk me through, you have a new Mohs defect. What does that look like? How do you size it up? How do you formulate this approach with the patient?

Michael Fritz: Yeah, so obviously it's different for every subside in the face. You want to make incisions where you won't see the scars. So, you want to do it at the border lines, say at the edge of the eyelid and go around the cheek and in front of the ear if you've got a big cheek defect. So sometimes you actually make much bigger incisions than you think you need to because you're hiding all of these, these reconstructions. And then, you know, the most complicated reconstructions are probably ones of the lips and the nose and in particular the nose. And in, and in that instance, you have to think in layers. There's the lining of the nose, there's the structure, and then there's the surface. And the surface is the most kind of daunting to the lay person because they see, oh, well, all your skin's missing from your nose.

But if you've got your cartilage and you've got the lining, well then you just bring in some tissue from either the cheek or the forehead and do a meticulous kind of staged approach. And it's pretty straightforward. It's those defects where you've got everything gone that just go in order of magnitude more difficult. And the way we look at these is, you know, you have to, you have to replace all of those parts and you have, it's like shooting pool. You have to set up your next stage. These are in, in contrast to some of the other cancer reconstructions we do, are staged. So, you bring in structure and if you can establish function, that's the next thing you do, either at the same setting or the, or the setting after that. And then you worry about the form. So, the classic example is the big nasal reconstruction with the forehead flap.

We have to bring in lining. Sometimes it's as complicated as doing a little mini fascia lata, a free flap for lining. You have to bring in structure that could be cartilage from the ear or bone from the rib, rib cartilage, whatnot. And then a covering on top, which is a forehead flap. And often you'll do that part of reconstruction there, and then you'll have to lift the forehead flap again and thin it and put some more graphs and not divide the, the pedicle. So, they look pretty bad for a while. You have to be patient. And then eventually you divide all the pedicles, and you insert it, and then you've got something that looks a lot like a nose. Then you let it heal for a while, and then very often you need to go back again and then sculpt it either in the office or as a minor procedure.

But you, you know, the name of the game is symmetry and function. So, you know, I counsel patients, I'm like, look, this is a process. It's going to be, it could be six months, it could be a year before we get you exactly where we want you. But as long as I think I can make you go forward without going backwards, that's what we're going to do. I tell folks, I'm done with you when you're done with me, as long as it's not going to compromise your outcome. You know, sometimes we can't get perfect. So, we have to, those are tough decisions, but we are going for perfect. We're going for “go through the grocery store and no one looks twice at you.” And usually, we can get people there.

Paul Bryson: Any take home messages for our dermatologists or other Mohs surgeons who may be listening about how we can help with reconstruction?

Michael Fritz: Well, again, I think in most instances, maybe 98 percent of the time well-trained folks on the outside are the perfect folks to take care of this. It's just when you're, when you're in a situation where a multidisciplinary approach is more advantageous, or if the patient's going to need adjunctive therapy rapidly, or where they potentially have a very complex reconstruction, I think, you know, having us, you know, cooperate and collaborate with those folks is a great idea. You know, so we, we are happy to be the backup for people if they need it.

Paul Bryson: Well, for more information on Mohs surgery and reconstruction, visit ClevelandClinic.org/MohsSurgery. That's ClevelandClinic.org/MohsSurgery. And to speak with one of our facial plastic and reconstructive surgeons or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Fritz, thanks for joining Head and Neck Innovations.

Michael Fritz: Thank you. It's my pleasure.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.