Correspondence and Brief Communications Correspondence and brief communications are wel- comed and need not concern only what has been published in this journal. We shall print items of interest to our readers, such as experimental, clinical, and philosophical observations; reports of work in progress; educational notes; and travel accounts relevant to plastic surgery. We reserve the right to edit communications to meet requirements of space and format. Any financial interest relevant to the content of the correspondence must be disclosed. Submission of a letter constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the journal and in any other form or medium. The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the journal. Any stated views, opin- ions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such letters. MOHS SURGERY: AN INFORMED VIEW Sir: Plastic surgeons, like most other physicians, cringe when they see increasingly common sensationalistic headlines such as “My Plastic Surgery Nightmare” in the popular press. These physicians legitimately complain that such articles do little to promote patient well being, as they inject overly charged emotion, bias, innuendo, and anecdotal evidence into de- bates about the successes and failures of surgical procedures. We were similarly disappointed when the esteemed journal Plastic and Reconstructive Surgery recently published “Mohs Sur- gery Out of Control” as a Letter to the Editor. 1 This letter, although certainly aimed at promoting patient welfare, is replete with theatrical hyperbole, factual error, blatant mis- information, and misguided apprehension. We would there- fore like to address some of the most contentious points in Dr. Glass’s letter. Most importantly, we wonder whether Dr. Glass has ever seen or participated in a Mohs micrographic surgery case. With more personal exposure to the Mohs surgical tech- nique, Dr. Glass would certainly realize that any patient un- dergoing this procedure is not left to spend “8 hours on the doctor’s table with no intravenous drips and nothing by mouth.” Although in some instances the duration of a day in a Mohs surgery clinic can be undeniably long, the procedure is performed exclusively as a staged surgical excision. Because the actual tumor extirpation procedure under local anesthe- sia takes only minutes, the vast majority of the patient’s day is spent in a waiting facility in a nonsedated state with full access to food and drink and the company of loved ones. We have neither seen nor heard of a Mohs practice where a patient is left on a treatment table for hours on end. Such a dereliction of care would certainly be worthy of criticism. Because the majority of the patient’s time is spent waiting for the Mohs surgeon’s pathological examination of the excised tissue, the patient should be no more prone to dehydration than in any other setting, including in his or her own resi- dence. Mohs surgery patients are not kept on a nothing-by- mouth basis, because sedation is not typically required, and there is therefore no clinical need for routine intravenous volume replenishment. Finally, the author’s suggestion that Mohs surgeons generally excise more tissue than their sur- gical colleagues do is blatant misinformation. The entire premise of the Mohs technique involves careful mapping of clinically inapparent tumor to provide more accurate tumor removal and to minimize the excision of adjacent histologi- cally normal tissue. If the patient cared for by Dr. Glass had a large surgical defect after Mohs surgery, there is only one plausible clinical explanation: the patient had a large tumor with clinical margins that were underestimated before the malignancy’s surgical removal or with surgical margins that could not be adequately recognized with traditional patho- logic examination techniques. Of course, it has previously been published in the plastic surgery literature that tradi- tional margin examination procedures (bread-loafing tech- niques) actually examine only about 1 percent of the actual lateral and deep surgical margins. 2 Because the Mohs tech- nique more meticulously examines the entire true surgical margins, it is not surprising that the defects that result from tumor removal can occasionally be significantly larger than anticipated before the initiation of surgical care. Although the exact excision of a cutaneous malignancy is the most important aspect of Mohs surgery, tissue conservation is also a cornerstone of the Mohs technique. Published studies in the surgical literature have confirmed that the Mohs technique removes much less tissue than conventional surgical tech- niques 3 and that the reconstructive procedures that need to be performed subsequently are typically far less complicated than those envisioned before excision of the tumors. 4 The frequent suggestions that surgical procedures should not occur outside traditional operating room facilities are often self-serving. Unfortunately, the assumptions that oper- ating room– based environments are uniquely safe are often based on precedence and tradition rather than on scientific fact. In an outpatient setting, Mohs surgery and the subse- quent reconstructive procedures (performed by suitably trained dermatologists) have been shown to be exquisitely safe. 5 Furthermore, Dr. Glass’s argument that these types of surgical procedures should occur only in accredited facilities also has weakness, as studies have clearly shown that horren- dous surgical outcomes in procedures such as liposuction occur even among board-certified surgeons with hospital privileges. 6 The overwhelming majority of American patients with skin cancer are treated by dermatologists in outpatient settings. 7 Any efforts to increase the number of skin cancer patients treated in hospital settings will have enormous ramifications on Medicare spending. 8 To date, there are no scientific stud- 945