Modified peripheral and central Mohs micrographic surgery fo
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A 70 year-old woman presented for recurrent vulvar EMPD and consideration of MMS to assist with tumor extirpation. In 2016, the patient underwent WLE with multiple positive radial margins on final pathology. Dermal invasion was absent with the exception of a minute focus to a depth of 0.01 cms. The tumor recurred locally and multiple scouting biopsies were performed by gynecologic oncology demonstrating epidermally limited disease involving the mons along the right side in the peri-clitoral area down to the labia minora, in addition to the left side of the clitoral hood.

The patient was treated with several three-month courses of topical imiquimod 5% cream three times weekly in an effort to spare a repeat WLE. These treatments resulted in limited response, as confirmed by persistent disease on repeat biopsies, and significant local irritation so surgical excision was recommended.

To accurately achieve clear margins and ensure there was no vaginal or urethral involvement which can sometimes be unresectable, a novel technique was performed employing dual inner (mucosal) and outer (external genital skin) Mohs margins. Similar in application to the “spaghetti technique,” a thin tissue layer was excised around the clinically apparent tumor margins, both peripherally in skin (5 mm) and circumferential to the urethra and vaginal orifices (3 mm). The inner margin was clear on the first stage. The defect was not repaired to allow for visualization of the medial margin for the subsequent excision of the central tumor-bearing island planned for by gynecologic oncology under general anesthesia.

Four Mohs stages were required to achieve clear peripheral margins. The outer ring was temporarily repaired to ensure hemostasis and wound stability until planned partial superficial vulvectomy with preservation of the clitoral organ. This was performed a few days later by gynecologic oncology and reconstructed with bilateral V-Y island pedicle advancement flaps by a plastic surgeon. Vulvectomy tissue showed no dermal invasion. EMPD was confirmed by cytokeratin (CK7) positivity.

The patient had no evidence of post-operative recurrence after six months, with benign findings from two skin biopsies of the mons and right perianal/gluteal region.