Mohs micrographic surgery versus surgical excision for periocular basal cell carcinoma

Review question
To compare the effectiveness, cost, complications and acceptability of two different surgical techniques for treating basal cell carcinoma (BCC) around the eyes.

BCC is the commonest skin cancer and the most common cancer in people of white origin. It is usually seen on the sun exposed parts of the body like the face, neck, head and ears. Untreated lesions can slowly eat away the surrounding skin and hence they are also called "rodent ulcers".

The commonest treatment for BCC is surgery. This is traditionally achieved by surgical excision (SE) which involves cutting away the BCC, along with a margin of normal appearing skin around it to ensure complete removal of the cancer and to reduce the risk of recurrence.

Another type of surgery is Mohs micrographic surgery (MMS). This involves the removal of the skin tumour after colour coding the edges. This is then examined under the microscope to see if all the BCC has been removed. If any residual BCC is left at any particular edge further skin is removed from only that localised area by using the colour coding, and examined under the microscope. This process is continued until all the BCC is removed. This ensures complete tumour removal and spares normal tissue in the other directions.

MMS is considered the better alternative for treatment of certain types of BCC arising in the eyelids because it has the highest chance of curing the disease and minimises the size of the defect that needs to be repaired.

Unfortunately, this treatment is not available everywhere and not always employed because of practical limitations in the service delivery.

Surgical excision is thought to be a cheaper option as it does not require the special training, multiple procedures, and money involved in setting up and running a MMS service. However, longer duration of follow up, greater surgical morbidity and the cost of dealing with recurrences may over time significantly increase the cost of SE.

Study characteristics
We searched for studies where people with BCC had been randomly selected to be treated by one or the other method. The aim was to establish which treatment method is associated with lower recurrence rate. We also looked at the cost difference, complications and acceptability of the two procedures.

Key results
No studies were found that met the inclusion criteria.

Authors' conclusions: 

No reliable conclusions could be reached regarding which method of treatment (SE or MMS) resulted in a lower recurrence or complication rate for periocular BCC. No studies were found comparing the cost of either method directly.   

High quality RCTs are therefore needed to improve the evidence base for the management of this condition.

Read the full abstract...

Basal cell carcinoma (BCC) is the commonest skin cancer in the white population. It is traditionally treated by surgical excision (SE) or by Mohs micrographic surgery (MMS).  


The objective of this review was to compare the effectiveness, cost, complications and acceptability of periocular BCCs when operated by MMS or SE.

Search strategy: 

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 1), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2014), EMBASE (January 1980 to February 2014), the metaRegister of Controlled Trials (mRCT) (, ( and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) ( We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 February 2014.

Selection criteria: 

We planned to include only randomised controlled trials (RCTs) comparing SE with MMS for treatment of periocular BCC.

Data collection and analysis: 

We did not find any studies that met the inclusion criteria for this review.

Main results: 

We did not find any studies that met the inclusion criteria for this review and hence none were included for analysis. Results of non-randomised studies describing the individual techniques are reported.