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Background: The skin fixative used in Mohs chemosurgery contains zinc chloride and is referred to as Mohs paste (MP). However, MP shows a remarkable change in rheological characteristics after its preparation. Objective: To prepare an MP with stable rheological characteristics, we prepared a modified MP (mMP) using zinc oxide 10% single ointment (Zn_ointment), which is an oil-based ointment. Methods: We evaluated mMP by determining its rheological characteristics, depth of tissue fixation, and observation of the tissue surface after treatment. Results: The viscosity of mMP increased after three months. However, the treatment-dependent viscosity of mMP could be obtained by mixing with glycerin. The viscosity and spreadability of mMP_3mth, which was three months after preparation, were 1992.0 ± 376.5 Pa·s and 2.1 ± 0.1 cm, respectively. In contrast, the viscosity and spreadability of MP mixed with glycerin were 436.9 ± 0.0 Pa·s and 2.8 ± 0.0 cm, respectively. The fixed invasion depth of MP was sign...

Mohs' chemosurgery is a technique of chemical fixation of a cutaneous tumor using 20% zinc chloride, and the surgeon performs a sequential series of excisions until no residual tumor can be found in the bottom layer of the specimen by microscopic examination. This technique has also been gradually accepted as one of the palliative treatment options in patients with cutaneous tumors with risk factors for surgery. We report three cases of cutaneous squamous cell carcinoma that were treated with Mohs' chemosurgery for palliative purposes. In case 1, Mohs' chemosurgery could prevent rapid tumor growth and control the bleeding, exudation and offensive odor from ulcerated tumors. The patient was able to live enjoyably at home with her family before she was transferred to a palliative care hospital. In case 2, Mohs' chemosurgery followed by debridement of residual tumor and a full-thickness skin graft contributed to an early hospital discharge, which prevented the progression of cognitive decline. In case 3, remission of the tumor was achieved by concurrent treatment with local radiotherapy and Mohs' chemosurgery. Mohs' chemosurgery for palliative purposes is not a radical treatment, but contributes to the patient's quality of life. It has the possibility of becoming a radical treatment if eligible patients and concurrent treatment are carefully selected. An increase in the number of skin cancer patients with risk factors for surgery has been predicted because of the progression of the aging society. Mohs' chemosurgery may become one of the treatment options for such patients.

An 89-year-old woman was given a diagnosis of senile dementia of Alzheimer type around 2003. In 2006, the patient was examined at a dermatology clinic complaining of tumor in the right buccal region. At the time, possible squamous carcinoma was pointed, but nothing was done for it. In March 2008, home care became difficult due to progression of dementia, and the patient was admitted to our hospital. On admission, a protruding skin tumor (20 x 20 x 2 mm, cauliflower-like surface) was observed in the right buccal region. Surgical ablation was recommended, however, the family strongly requested to let it follow its in natural course. In December 2008, the tumor increased rapidly to 40 x 55 x 25 mm with bleeding and a bad smell, which decreased her QOL markedly. After obtaining consent from the patient and her family, Mohs chemosurgery was performed. As the result, the tumor resolved and the QOL improved. Mohs chemosurgery is considered as a very effective treatments for rapidly advancing progressive skin cancer in patients with severe cognitive impairment.

Mohs' chemosurgeryは腫瘍を化学的に固定化して切除する方法である。今回，右外耳道癌の転移性皮膚腫瘍に対して本治療を施行した。症例は48歳男性。2007年7月に本疾患に対して右側頭骨外側切除術，右頸部郭清術および右耳下腺浅葉切除術，その後放射線治療を施行した。治療後，放射線性側頭骨壊死が出現したが，2008年4月より右耳介後部の皮膚に再発が認められた。化学療法を行ったが，腫瘍は手拳大に急速に増大して，断続的な浸出液と出血，強い悪臭が出現し，全身状態の衰弱とともに患者のQOLは低下を示した。根治治療が不可能と考え，Mohs' chemosurgery法をmodifyして行った。腫瘍表面にMohs'ペーストを塗布し，24時間後に灰白色に固定化された腫瘍を切除した。同手法を3回繰り返して行うと，腫瘍は著明に縮小して出血や浸出液，悪臭はほぼ消失し，患者の疼痛は軽減した。Mohs' chemosurgeryは，腫瘍縮小に加えQOLを重視した緩和ケアに有用な治療法として期待される。

Today the fixed tissue technique is primarily of historical significance. A multidisciplinary approach to difficult skin cancers, the limited availability of the zinc chloride fixative, and the dwindling pool of Mohs surgeons with expertise in this technique have resulted in Mohs chemosurgery becoming a dying art.

Cryosurgery is an excellent procedure in the treatment of malignancies when properly selected patients, appropriate tumors, adequate instrumentation, and proper technique are combined. 1 It is the treatment of choice for some skin cancers, and an alternate for many others in comparison with Mohs chemosurgery, conventional surgery, electrosurgery, and radiotherapy.

Mohs fresh-tissue technique for difficult cutaneous malignancies is well known and widely accepted. Less widely known by general dermatologists is Mohs chemosurgery, the technique that launched the career of Frederick Mohs, MD, surgeon. His technique used a dark escharotic paste containing zinc chloride, bloodroot, and stibnite for in situ tissue fixation followed by microscopically controlled mapped excision. Virtually unknown today is Perry Lewis Nichols, MD (the Nichols Sanatorium and the Nichols escharotic method). Dr Nichols developed a bsecretQ escharotic formula that was used to treat more than 70,000 patients with mainly skin, mucosal, and breast cancer. Starting in Iowa (1896), the sanatorium achieved remarkable growth in Hot Springs, SD (1905-1915), expanded to Excelsior Springs, Mo (1911), and had its greatest success in Savannah, Mo (1912-1956). My interest in Perry Nichols began, unknowingly, at 5 years of age when I first laid eyes on the frightening appearance of great uncle Joe at a family reunion with a stork-like white scarf around his head covering a hole in his sagging cheek. That interest increased when my practice was established in St Joseph, Mo, 13 miles south of the former sanatorium. In the last 4 years the interest has become intense with success in acquiring Nichols Sanatorium yearbooks (Cancer and its Proper Treatment—The Value of Escharotics: Medicines which will Destroy any Living or Fungous Growth in the Treatment of CancerLupus-Sarcoma or Any other Form of Malignancy) and interviewing nurses and employees who worked at the

The case records of 52 patients with 55 cutaneous neoplasms treated by Mohs' chemosurgery and subsequently reconstructed by plastic surgeons were reviewed to determine if delay between resection and reconstruction adversely affected the outcome of reconstruction. Reconstruction was performed from 5 to 61 days after Mohs' chemosurgery for 45 basal cell carcinomas and 10 other cutaneous neoplasms. There were no complications during the interval between resection and reconstruction. Following reconstruction, minor wound complications occurred in 6% of patients; there were no major complications. Microscopic examination of the re-excised wound revealed residual disease in 2 of 45 cases of basal cell carcinoma and 0 of 10 other cutaneous malignancies. Both patients with residual basal cell carcinomas (i.e., false-negative margins after Mohs' surgery) had presented to the Mohs' surgeon with recurrent tumors. During a follow-up period of 3 months to 3 years after complete resection, recurrent tumor developed in 2 of 45 cases of basal cell carcinoma and 3 of 8 cases of squamous cell carcinoma. Delayed reconstruction, usually 5 to 20 days after Mohs' chemosurgery, can be performed without significant morbidity. Re-excision of the Mohs' chemosurgical wound for pathologic examination can detect residual disease and may be especially indicated for large recurrent wounds.

In two cases of epithelioma cuniculatum, a rather rare form of verrucous carcinoma of the plantar surface of the foot, the lesions were excised by means of microscopically controlled surgery (Mohs' chemosurgery) with successful results, both clinically and cosmetically. Although the tumor is generally slow-growing and often mistaken for a plantar wart, it can cause extensive local destruction. Metastasis has been reported and may be related to anaplastic transformation caused by radiotherapy. In certain cases, amputation may possibly be avoided through the use of microscopically controlled surgery.

We report a case of osteomyelitis complicating Mohs' surgery for recurrent basal cell carcinoma of the forehead. The need for immediate versus delayed repair after this type of surgery is discussed. It is evident that open, bone-exposed defects allowed to heal by secondary intention require meticulous wound care and follow-up.

Subungual Bowen's disease and squamous cell carcinoma are not as rare as has been implied by earlier literature. The course of the lesions is protracted. Clinically the diseases may mimic onychomycosis, chronic paronychia, eczema, verruca vulgaris, pyogenic granuloma, subungual exostosis, or malignant melanoma. Histologic examination is the key to diagnosis. As only two metastases have occurred in 110 patients, subungual epidermoid carcinomas should be regarded as low-grade malignancies that can be managed by conservative surgical ablation. The microscopically controlled excision technic (Mohs chemosurgery) is ideal for these tumors. Amputation of the affected digit is too drastic, especially when the thumb, the most common site, is involved.

The external auditory canal represents an area of high risk for recurrence of tumors. Therefore, carcinomas involving this region should be removed by Mohs chemosurgery. Healing by granulation can result in stenosis of the canal. We report a method of reconstruction to prevent stenosis of the auditory canal after chemosurgery.

A 59-year-old black woman presented with an ill-defined plaque on her nose. This appeared clinically suggestive of a sclerosing type of basal cell epithelioma (BCE). Microscopic sections demonstrated this diagnosis. Multiple excisions employing the microscopically controlled technique of Mohs traced the tumor deep into the nasal cartilage before histologic sections were free of tumor cells. This type of BCE deserves well planned therapy because of its destructive potential.

B ASAL CELL carcinoma of the scaIp has engaged the attention of surgeons and radiotherapists for many years. Its treatment, however, is beset with many difficulties and IocaI recurrences are commonpIace. Because of the Iatter probIem, we began in June 1960 to treat a seIected group of patients with superficia1 skin cancers by the Mohs’ chemosurgery technic [I]. This method introduced by Mohs into the surgica1 Iiterature in 1941 appeared to us to have certain advantages in the treatment of skin cancer that was not apparent in the more conventiona forms of surgery and radiation, nameIy, (I) the tumor is excised by microscopic contro1, (2) the resuItant wound in most cases is permitted to hea by secondary intention, (3) the procedure is bIoodIess and (4) in many instances the patient is treated on an outpatient basis. Because coIIective experience with Mohs’ technic is Iimited, this report represents our experience with this method of therapy in treating basa1 ceI1 carcinoma of the scaIp.

Four patients with a primary histological diagnosis of Bowen disease of the nail bed were treated by the Mohs chemosurgery technique. The presence of invasive squamous cell carcinoma was disclosed during chemosurgery in three cases. The fourth case had already progressed to invasive squamous cell carcinoma before treatment. It is urged that biopsies be performed in all cases of persistent and recurrent disease of the nail bed so that an early diagnosis may be made and treatment instituted before the development of invasive carcinoma. Mohs chemosurgery permits adequate excision of the tumor with maximal preservation of normal tissue and function.

• Verrucous carcinoma, a variant of squamous cell carcinoma, is recognized as a distinct clinicopathologic entity. It occurs principally in three anatomic sites: panoral, genitogluteal, and plantar. Two cases of plantar verrucous carcinoma treated by the Mohs' chemosurgery technique are reported, and the literature is reviewed. The clinical and pathologic appearance of these lesions make them recognizable in a patient with a persistent plantar lesion usually diagnosed as a wart but unresponsive to conventional therapy. The role of irradiation, a possible viral etiology of the tumor, and the necessity for a deep biopsy are discussed. Because these tumors are characterized by extensive local growth, Mohs' chemosurgery is proposed as the treatment of choice. In this way, total tumor ablation is obtained with maximum preservation of normal tissue structure and function. ( Arch Dermatol 116:794-797, 1980)

Petres and Hundeiker of the dermatologic university clinics of Freiburg and Giessen, respectively, cooperated in writing a monograph entitled Corrective Dermatology: Operations on the Skin . Their teacher, Kalkoff, director of the Dermatologic Unversity Clinic of Freiburg, points out in the preface that corrective dermatology has had a firm place in dermatology since the end of the last century. Lang of Vienna was famous for his plastic surgical operations on lupus vulgaris. More recently, Schreuss of Dusseldorf and Moncorps of Munich taught and practiced operative methods of corrective dermatology. The text describes various procedures in the treatment of numerous skin lesions, in particular, benign and malignant tumors. Discussed in detail are the bases of dermatosurgery, the necessary set of operative instruments, pre- and postoperative care, methods of inducing anesthesia, and techniques of incision and suturing. Dermabrasion, electrosurgery, and curettage are also mentioned. The authors have not had experience with Mohs chemosurgery

Experience in treating 1, 275 skin cancers with Mohs' chemosurgery is presented. The Mohs technic uses microscopic examination to avoid excision of normal tissue and assure complete removal of the tumor. Chemosurgery is indicated for tumors which are poorly demarcated or which arise in areas known to have a high recurrence rate. It is the procedure of choice for almost all recurrent lesions.

Superficial basal cell carcinomas of the chin and cheek are currently treated by electrical and chemical dissection, surgical excision, and radiation therapy. Each of these methods has proved its usefulness in the management of basal cell carcinoma; however, each has certain limitations as attested by the number of reports that have been published concerning the management of recurrent lesions. In our opinion, the principal factor responsible for the recurrence of a basal cell carcinoma is the failure of the initial method of therapy to totally eradicate the tumor. Because of this problem, we began in 1960 to treat a selected group of basal cell carcinomas of the face by Mohs' chemosurgery technique,1as it was our belief that this method offered certain advantages of insuring total tumor removal that were not apparent in the more conventional forms of therapy. Because collective experience with Mohs' chemosurgery technique is limited, it