๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
Physical examination
Physical examination
The physical examination is focused on identifying the tumor location, which should be documented prior to surgery and confirmed with the patient. Confirming the biopsy site is a prerequisite to proceeding with Mohs surgery, although this can be difficult in patients with severe actinic damage, multiple scars, rosacea, and many seborrheic or actinic keratoses. Photographs, diagrams, tangential lighting, Woodโs lamp, and magnification are helpful,20 as patients presenting for dermatologic surgery have been shown to be incorrect 16.6% to 31.4% of the time when attempting to identify their surgical site.21 If these measures are unavailable or unsuccessful, a protocol should be in place. One published protocol involves both physician and patient participation in biopsy-site identification at consultation. If the biopsy site was not identifiable, then further consultation was undertaken with the patientโs referring provider and/or family. Frozen biopsies were employed if necessary to identify tumor sites on the day the patient presented for surgery. If the biopsy site still could not be identified, then frozen biopsy specimens were sent for permanent sections and the patient was observed at 3- month intervals. Over a 6-year period, there were no cases of wrong-site surgery in 7983 MMSs performed; surgery was, however, occasionally deferred because the correct biopsy site could not be identified.22
On the other end of the spectrum, patients with extremely large or deeply invasive tumors, especially with motor nerve findings or lymphadenopathy, may require a multidisciplinary approach and preoperative imaging or consultation. Ophthalmology, otolaryngology, radiology, oncology, surgical oncology, neurosurgery, and plastic surgery may all at times be consulted by the Mohs surgeon in the perioperative period.