Simple Steps Like 3D Models and Smoke Evacuators Boost Mohs Surgery Patient Satisfaction

For patients facing skin cancer surgery, the experience of lying awake on the operating table can be as consequential as the operation itself. Mohs micrographic surgery, the gold-standard treatment for cutaneous malignancies, is unique among oncologic procedures in that patients remain fully conscious throughout, absorbing every conversation among the surgical team, every whir of an instrument, and every scent in the operating room. A new systematic review published in Archives of Dermatological Research has now systematically catalogued which perioperative interventions actually move the needle on patient satisfaction, and the findings offer both surprises and practical guidance for surgeons. The review, conducted by Jett Ramir, Joshua Burshtein, and Roger Haber of the University of Illinois-Chicago, analyzed nineteen studies spanning more than a quarter century and encompassing 3,494 patients across five countries.

The methodology behind the review was rigorous. The authors followed PRISMA guidelines, searching PubMed from database inception through August 2025 with terms combining Mohs micrographic surgery and patient satisfaction. Two independent reviewers screened the initial 183 records against predefined criteria, with disagreements resolved by consensus or a third reviewer. Eligible studies had to be peer-reviewed, published in English, conducted within the context of Mohs surgery, and designed to evaluate the effect of a perioperative intervention on patient satisfaction. The final set comprised fifteen randomized controlled trials, three retrospective observational studies, and one comparative study, with sample sizes ranging from just 24 participants to 1,250. Risk of bias was assessed independently by two reviewers using the National Institutes of Health Quality Assessment Tool, an important quality check given the heterogeneity of the underlying literature.

Measuring satisfaction proved to be a challenge in itself. The included studies employed a patchwork of instruments: twelve used Likert scales, two used patient satisfaction questionnaires, two used visual analog scales, two used investigator-developed surveys, and one used the FACE-Q Skin Cancer module. This instrument heterogeneity meant the authors could not pool results statistically and instead performed a qualitative synthesis. Perhaps the most striking finding, however, was not about any single intervention at all. Patient satisfaction was uniformly high across the board, regardless of what treatment patients received. The authors attribute this to a ceiling effect arising from the exceptionally high baseline satisfaction already observed in Mohs populations, where cure rates for primary basal cell carcinoma reach as high as 99 percent and 92 to 99 percent for squamous cell carcinoma.

Against that ceiling, four interventions broke through with statistically significant improvements in satisfaction. The first emerged in the preoperative phase: education using three-dimensional printed anatomical models. In a randomized trial by Biro and colleagues, 42 patients who received education via a 3D printed model of their own surgical anatomy showed improved procedural understanding, reduced preoperative anxiety, and significantly higher satisfaction on a Likert-type scale compared with 40 controls who received verbal education alone, a difference that reached statistical significance at p less than 0.03. The tactile and visual engagement of holding a physical replica of the surgical site appears to address multiple dimensions of the preoperative experience simultaneously, a quality that videos and pamphlets have struggled to replicate.

The second significant intervention was remarkably simple: letting patients look at their own surgical defect in a mirror before reconstruction begins. In a multicenter prospective cohort study, Veldhuizen and colleagues found that patients who viewed their facial skin cancer defect prior to closure reported dramatically higher satisfaction with their appearance, with an odds ratio of 8.66, and the effect persisted at twelve-month follow-up. This finding challenges the intuition that seeing a wound might be distressing. Instead, it appears that confronting the reality of the defect before it is repaired helps patients calibrate their expectations and appreciate the reconstruction, a form of psychological inoculation against the shock of the immediate postoperative appearance.

The third winning intervention targeted a sensory detail most surgeons never consider: smell. Because Mohs patients are awake, the acrid burning odor of electrocautery can be an unpleasant and memorable part of the procedure. In a cleverly designed comparative study, researchers attached a smoke evacuator to the electrocautery pen and activated it only during the closure stage, while maintaining the vacuum sound throughout all stages of the operation to preserve blinding. The results were dramatic. All patients perceived a burning odor during excision compared with only 40 percent during closure, patients were far less likely to report an unpleasant smell when the evacuator was active, 66.6 percent versus 16.6 percent at p less than 0.0001, and 76.7 percent rated the closure stage as more pleasant. Sometimes the difference between a good and bad surgical memory is literally the air in the room.

The fourth significant intervention came after the operation was over. Asilian and colleagues tested an oral wound-healing supplement containing bromelain, Centella asiatica, hyaluronan, vitamin C, zinc, and copper in a randomized, double-blinded, placebo-controlled trial. Patients receiving the supplementation showed significantly improved wound healing on the Early Healing Score and, critically, significantly higher satisfaction at two weeks on a visual analog scale, 9.08 versus 7.42 at p less than 0.001, the largest direct satisfaction effect in the entire review. The authors urge caution, however, noting that the small sample size and short follow-up duration mean this result requires confirmation in larger trials before it changes clinical practice.

Just as instructive are the interventions that failed to lift satisfaction scores but proved valuable in other ways. Educational videos, whether watched at home or integrated into the informed consent process, did not improve satisfaction across three randomized trials, yet patients consistently rated the content as informative and recommended it for future patients, suggesting value in preparedness even when the metric being tracked remained flat. Preoperative phone calls similarly showed no satisfaction benefit in two trials. Intraoperative anxiolytics told an interesting story: in a seven-armed randomized trial comparing lorazepam, diazepam, alprazolam, gabapentin, pregabalin, melatonin, and placebo, single-dose benzodiazepines and GABA-agonist medications proved safe and effective for reducing perioperative anxiety, even though satisfaction scores were uniformly high in every arm. A separate trial found significant within-group anxiety reduction with midazolam at p equal to 0.002, an effect absent in the placebo arm. Anxiety and satisfaction, the review makes clear, are related but distinct constructs that warrant independent measurement.

Other null results carried their own lessons. Handholding and stress balls made no difference to satisfaction or anxiety. Intravenous anesthesia was associated with significantly higher postoperative anxiety than local anesthesia, though possibly confounded by larger defect sizes. Postoperative telephone follow-up did not raise satisfaction, but same-night calls proved most effective at identifying active pain, offering a practical surveillance tool for early complication detection. A film-forming silicone gel dressing improved objective wound healing significantly without increasing contact dermatitis rates compared with triple antibiotic ointment, yet produced no corresponding satisfaction gain, a striking dissociation between clinical outcomes and what patients actually report feeling. Even surgical technique mattered less than expected for overall satisfaction, though melolabial island flap reconstruction yielded better donor site scar satisfaction than the paramedian forehead flap at p equal to 0.026.

The review’s authors are candid about the limitations constraining their conclusions. The analysis relied on a single database, PubMed, and was not prospectively registered, limiting methodological transparency. Only English-language publications were included, introducing language bias, and publication and outcome reporting biases may have underrepresented null results. The predominance of small, single-center randomized trials with heterogeneous instruments and bundled intervention designs makes it difficult to attribute effects to individual components. Their prescription for the field is clear: adequately powered, multicenter trials that isolate individual interventions, incorporate anxiety and preparedness as co-primary outcomes, employ standardized validated instruments, and account for demographic risk factors such as female sex, age of 65 or younger, and smoking, which are associated with worse scar-related outcomes. For now, the message for surgeons is refreshingly practical: hand patients a printed model of their own anatomy, let them look at the defect before you fix it, clear the smoke from the air, and the awake patient on your table may remember the operation far more fondly.

Subject of Research: Perioperative interventions and patient satisfaction in Mohs micrographic surgery for skin cancer

Article Title: Patient-centered perioperative interventions for mohs micrographic surgery: a systematic review

Article References: Patient-centered perioperative interventions for mohs micrographic surgery: a systematic review. (n.d.). https://doi.org/10.1007/s00403-026-04972-2

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04972-2

Keywords: Mohs micrographic surgery, patient satisfaction, systematic review, skin cancer, perioperative care, 3D printed models, smoke evacuation, wound healing, patient-reported outcomes, dermatologic surgery, anxiety reduction, surgical education