Sample Type / Medical Specialty: Dermatology
Sample Name: Mohs Micrographic Surgery - 2
Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.
(Medical Transcription Sample Report)
Basal Cell CA.POSTOP DIAGNOSIS:
Basal Cell CA.LOCATION:
Medial right inferior helix.PREOP SIZE:
1.4 x 1 cmPOSTOP SIZE:
2.7 x 2 cmINDICATION:
Poorly defined borders.COMPLICATIONS:
Wedge resection advancement flap.DESCRIPTION OF PROCEDURE:
Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.
The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision. With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique. A map was prepared to correspond to the area of skin from which it was excised. The tissue was prepared for the cryostat and sectioned. Each section was coded, cut and stained for microscopic examination. The entire base and margins of the excised piece of tissue were examined by the surgeon. Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.
No tumor was identified after the final stage of microscopically controlled surgery. The patient tolerated the procedure well without any complication. After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
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