Actas Dermo-Sifiliográficas (English Edition) Actas Dermo-Sifiliográficas (English Edition)
Actas Dermosifiliogr.2010;101:622-8 - Vol. 101 Num.7 DOI: 10.1016/S1578-2190(10)70684-3
Original article
Cost Analysis of Mohs Micrographic Surgery in High-Risk Facial Basal Cell Carcinoma
Análisis de costes de la cirugía micrográfica de Mohs en el carcinoma basocelular facial de alto riesgo
N. Blázquez-Sáncheza,b,, , M. de Troya-Martína,b, M. Frieyro-Eliceguia, R. Fúnez-Liébanac, L. Martín-Márquezd, F. Rivas-Ruize
a Servicio de Dermatología, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
b CIBER Epidemiología y Salud Pública (CIBERESP), Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
c Laboratorio de Anatomía Patológica, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
d Departamento de Económico, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
e Unidad de Investigación, Empresa Pública Hospital Costa del Sol, Marbella, Málaga, Spain
Received 14 November 2009, Accepted 17 February 2010

Mohs micrographic surgery (MMS) is the treatment of choice for high-risk facial basal cell carcinoma (BCC) as it offers the greatest chance of cure with maximum preservation of healthy tissue. Its use in Spanish public health care hospitals is still limited, however, due to the controversy surrounding its cost.


To determine the cost of MMS with fresh tissue to treat high-risk facial BCC and compare this to the estimated cost of conventional surgery in a Spanish public hospital. A secondary objective was to identify cost-optimization strategies for MMS.

Material and methods

Cross-sectional study of a consecutive series of patients with high-risk facial BCC who underwent MMS at the Department of Dermatology at Hospital Costa del Sol in Malaga, Spain between July 2006 and December 2007. We performed a descriptive analysis of the clinical characteristics of the patients and surgical factors. We calculated the total and mean cost of MMS and compared the results to the estimated costs of conventional surgery using patients as their own controls. Differences were analyzed according to tumor site and size, histologic subtype, and recurrence.


Seventy-nine patients (mean age, 62 years) with 81 high-risk facial BCCs, 97.5% of which were primary tumors, underwent MMS. The most common tumor site was the nose (57%) followed by the orbital region (25%). Histology showed that 64% of the tumors were infiltrative or micronodular carcinomas. Tumor-free margins were achieved in all patients, with no more than 2 stages required in 88% of the cases. The most common surgical reconstruction techniques were direct closure (21%) and closure with a local skin flap or graft (71%); the corresponding estimates for conventional surgery were 2% and 89%, respectively. The total and mean cost of MMS was €106 129.07 and €1325.80, respectively (compared to €97700 and €1208.70 for conventional surgery). The difference in mean costs between MMS and conventional surgery was not significant (P=.534).


MMS is a viable, effective technique that does not generate significantly higher costs than conventional surgery in selected patients with high-risk facial BCC. Certain technical and organizational strategies could contribute to optimizing the cost of MMS.


La cirugía micrográfica de Mohs constituye el tratamiento de elección del carcinoma basocelular de alto riesgo, pues ofrece la mayor garantía de curación con la máxima preservación de tejido sano. Sin embargo, su implementación en hospitales del ámbito sanitario público españoles es minoritaria hasta la fecha, debido a que el coste económico de esta técnica continúa siendo motivo de controversia.


Determinar los costes de la cirugía micrográfica de Mohs en fresco (CMF) en el tratamiento del carcinoma basocelular facial de alto riesgo (CBFR) frente al coste teórico mediante cirugía convencional (CC), en un centro hospitalario del ámbito sanitario público español. Identificar estrategias de optimización de costes en este tipo de cirugía.

Material y métodos

Estudio transversal de una serie consecutiva de pacientes con CBFR intervenidos mediante CMF en el Servicio de Dermatología del Hospital Costa del Sol desde julio 2006 a diciembre 2007. Se realizó un análisis descriptivo de las características clínicas de la serie y aspectos quirúrgicos. Se realizó un estudio de costes (coste total y coste medio) de la CMF y se compararon con los costes teóricos de la CC, utilizando cada paciente como su propio control. Se analizaron las diferencias por localización, tamaño del tumor, histología y recurrencia.


Se intervinieron con CMF 79 pacientes con 81 CBFR (edad media = 62 años). El 97,5% fueron tumores primarios. La localización más frecuente fue la pirámide nasal (57%) seguida de la región orbitaria (25%). El 64% correspondieron a tipos histológicos infiltrativo y micronodular. La exéresis tumoral mediante CMF se concluyó en todos los casos con márgenes libres, requiriéndose en el 88% únicamente uno o dos estadios. Las técnicas de reconstrucción quirúrgica más empleadas fueron el cierre directo y colgajo local (21 y 71% de los casos respectivamente en la CMF, frente al 2 y 89% en la CC). El coste total y coste medio de la CMF fue de 106.129,07 y 1.325,8 euros respectivamente (frente a 97.770 y 1.208,7 euros de la CC). La diferencia de costes entre ambos procedimientos no fue significativa (p = 0,534).


LA CMF es una técnica factible, eficaz y que genera costes que no son significativamente superiores a los de la CC en pacientes seleccionados con CBFR. Algunas estrategias técnicas y organizativas pueden contribuir a la optimización de costes de esta cirugía.

Palabras clave
Cirugía micrográfica, Mohs, Análisis de costes, Coste/beneficio
Micrographic surgery, Mohs, Cost analysis, Cost-effectiveness
This article is only available in PDF
K. Mosterd,G.A. Krekels,F.H. Nieman,J.U. Ostertag,B.A. Essers,C.D. Dirksen
Surgical excision versus Mohs’ micrographic surgery for primary and recurrent basal cell-carcinoma of the face: a prospective randomised controlled trial with 5-years’ follow-up
Lancet Oncol., 9 (2008), pp. 1149-1156
F.J. Bath-Hextall,W. Perkins,J. Bong,H.C. Williams
Interventions for basal cell carcinoma of the skin
Cochrane Database Syst Rev., 1 (2007), pp. CD003412
I. Leibovitch,S.C. Huilgol,D. Selva,S. Richards,R. Paver
Basal cell carcinoma treated with Mohs surgery in Australia II. Outcome at 5-year follow-up
Journal of the American Academy of Dermatology, 53 (2005), pp. 452-457
D.E. Rowe,R.J. Carroll,C.L. Day
Long-term recurrence rates in previously untreated (primary) basal cell carcinoma: implications for patient follow-up
J Dermatol Surg Oncol., 15 (1989), pp. 315-328
N.R. Telfer,G.B. Colver,C.A. Morton
Guidelines for the management of basal cell carcinoma
Br J Dermatol., 159 (2008), pp. 35-48
J. Cook,J.A. Zitelli
Mohs micrographic surgery: a cost analysis
J Am Acad Dermatol., 39 (1998), pp. 698-703
T.L. Bialy,J. Whalen,E. Veledar,D. Lafreniere,J. Spiro,T. Chartier
Mohs micrographic surgery vs traditional surgical excision. A cost comparison analysis
Arch Dermatol., 140 (2004), pp. 736-742
B.A.B. Essers,C.D. Dirksen,F.H.M. Nieman,N.W. Smeets,G.A. Krekels,M.H. Prins
Cost-effectiveness of Mohs micrographic surgery vs surgical excision of basal cell carcinoma of the face
Arch Dermatol., 142 (2006), pp. 187-194
S.Y. Then,R. Malhotra,R. Barlow,H. Kurwa,S. Huilgol,N. Joshi
Early cure rates with narrow-margin slow-Mohs surgery for periocular malignant melanoma
Dermatol Surg., 35 (2009), pp. 17-23
B. Stenquist,M.B. Ericson,C. Strandeberg,L. Mölne,A. Rosén,O. Larkö
Bispectral fluorescence imaging of aggressive basal cell carcinoma combined with histopathological mapping: a preliminary study indicating a possible adjunct to Mohs micrographic surgery
Br J Dermatol., 154 (2006), pp. 305-309
P. Redondo,M. Marquina,M. Pretel,L. Aguado,M.E. Iglesias
Methyl-ALA induced fluorescence in photodynamic diagnoses of basal cell carcinoma prior to Mohs micrographic surgery
Arch Dermatol, 144 (2008), pp. 115-117
A. Jambusaria-Pahlajani,C. Schmults,C. Miller,D. Shin,J. Williams,S.K. Kurd
Test characteristics of high-resolution ultrasound in the preoperative assessment of margins of basal cell squamous cell carcinoma in patients undergoing Mohs micrographic surgery
Dermatol Surg, 35 (2009), pp. 9-16
J.K. Karen,D.S. Gareu,S.W. Duzsa,M. Tudisco,M. Rajadhyaksha,K.S. Nehal
Detection of basal cell carcinomas in Mohs excisions with fluorescent confocal mosaicing microscopy
Br J Dermatol, 160 (2009), pp. 240-245
R. Alkalay,J. Alkalay,A. Maly,A. Ingber,C. Fritsch,T. Ruzicka
Fluorescence imaging for demarcation of basal cell carcinoma tumor borders
J Drugs Dermatol, 7 (2008), pp. 1033-1037
V.Q. Chung,P.J. Dwyer,K.S. Nehal,M. Rajadhyaksha,G.M. Menaker,C. Charles
Use of ex vivo confocal laser microscopy during Mohs surgery for non melanoma skin cancer
Dermatol Surg, 30 (2004), pp. 1470-1478
R.N. Downes,N.P. Walker,J.R. Collin
Micrographic (Mohs’) surgery in the management of periocular basal cell epitheliomas
Eye (Lond), 4 (1990), pp. 160-168
I. Leibovitch,S.C. Huilgol,D. Selva,S. Richards,R. Paver
Basal cell carcinoma treated with Mohs surgery in Australia. Outcome at 5-year follow-up
J Am Acad Dematol, 151 (2004), pp. 141-147
C. Leiter,U. Gaiber
Epidemiology of melanoma and nonmelanoma skin cancer-the role of sunlight
Adv Exp Med Biol, 624 (2008), pp. 89-103
R.S. Batra,L.C. Kelley
Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with Mohs micrographic surgery
Arch Dermatol, 138 (2002), pp. 1043-1051
I.F. Orengo,S.J. Salasche,J. Fewkes,J. Khan,J. Thornby,F. Rubin
Correlation of histologic subtypes of primary basal cell carcinoma and number of Mohs stages required to achieve a tumor-free plane
J Am Acad Dermatol, 37 (1997), pp. 385-387
T. Alonso,P. Sánchez,González,J. Ingelmo,I. Ruiz,S. Delgado
Cirugía de Mohs: nuestros primeros 100 pacientes
Actas Dermosifiliogr, 99 (2008), pp. 275-280
J.S. Rhee,B.A. Matthews,M. Neuburg,B.R. Logan,M. Burzynski,A.B. Nattinger
The skin cancer index: clinical responsiveness and predictors of quality of life
Laryngoscope, 117 (2007), pp. 399-405
Corresponding author.
Copyright © 2010. Academia Española de Dermatología y Venereología and Elsevier España, S.L.
Actas Dermosifiliogr.2010;101:622-8 - Vol. 101 Num.7 DOI: 10.1016/S1578-2190(10)70684-3