MILLENNIUM PAPER
The History and Evolution of Mohs Micrographic Surgery
David G. Brodland, MD,* Rex Amonette, MD,† C. William Hanke, MD,‡ and
Perry Robins, MD§
*Pittsburgh, Pennsylvania; †Memphis, Tennessee; ‡Carmel, Indiana; and §New York, New York
“In as much as the future of the field is largely uncharted,
it is unlikely that any but individuals with a flare for pio-
neering will be interested.”1
Dr. Frederic E. Mohs wrote this passage in his 1956
textbook to describe the likely character traits of early
practitioners who would embrace, advance, and refine
his technique of cancer removal. Dr. Mohs was, him-
self, a pioneer in the truest sense of the word (Figure
1). The concept of Mohs micrographic surgery was
born a mere generation following the dawn of modern
surgery. Handley’s article,2 which for the first time put
forth the concept of adequate margins of excision for
melanoma, surely provided stimulus to perfect a pro-
cess which completely, effectively, and dependably ex-
tirpated cutaneous carcinomas. Up to that time, surgi-
cal margins were strictly the prerogative of the
surgeon. Since then, the technique that the young Fre-
deric Mohs was to develop has, by virtue of its irrefut-
able logic, highly documented clinical success, and
practical efficacy, become the gold standard in tissue
conservative skin cancer removal.
Dr. Mohs acknowledges the contributions of many
before him who made the concept of micrographic
surgery possible. The first significant contribution was
the concept of killing cancer tissue with chemicals
which can be traced back to the ancient Egyptians
who used arsenic.1 Sir Humphry Davy first observed
zinc chloride’s caustic action on tissues. Later in the
18th century, Canquoin of France and Bougard of Bel-
gium investigated the use of this chemical for the treat-
ment of cancer patients. Chemical cauterization surgery
for cancer was then practiced by relatively few physicians
and a host of “irregular practitioners” throughout the
ensuing 150 years. However, at the time that Dr. Mohs
developed the concept of microscopic chemosurgery,
the “chemosurgeons” of that day were not a highly re-
spected group. In fact, most of those practitioners
were considered misguided charlatans and quacks.
The stories of disastrous cases and results from blind
cauterization with zinc chloride and other chemical
cauterants abounded. The first mention of zinc chlo-
Address correspondence and reprint requests to: David G. Brodland,
MD, Shadyside Medical Center, 5200 Centre Ave., Suite 303, Pitts-
burgh, PA 15232.
© 2000 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.
ISSN: 1076-0512/00/$15.00/0 • Dermatol Surg 2000;26:303–307
ride as a chemical cauterant of the skin was by Pusey
in the Journal of American Medical Association in
1910.3 Nonetheless, when Dr. Mohs observed quite
coincidentally that when zinc chloride was injected
into tissue, the tissue was histologically preserved and
could be examined in great cytologic detail under the
microscope, he pursued its use as a means to micro-
scopically extirpate cancers.1
Dr. Mohs’ pursuit of this radical concept was en-
abled by Professor Michael Guyer, the University of
Wisconsin geneticist and head of the zoology depart-
ment. As his research assistant, Dr. Mohs was given
considerable freedom to carry out any research project
on his own as long as it had something to do with can-
cer. In fact, Dr. Mohs’ observations about zinc chlo-
ride were made during a project that he and Dr. Guyer
worked on delineating the effects of injecting platinum
and other chemicals into implanted cancers in rats.
They were particularly interested in the effect on can-
cer from the inflammation these chemicals cause. The
chemical was injected and the tumor nodules were
shaved off horizontal to the skin. The tumors were
then examined microscopically in the horizontal plane.
This experimental technique was the genesis of the
concept of horizontal sectioning, so basic to modern
micrographic technique. An unexpected observation
was the excellent retention of histologic structure in
tissues injected with zinc chloride. It was at that point
that he envisioned the concept of chemical fixation,
saucerized surgical excision, and microscopic exami-
nation of horizontal sections to confirm tumor re-
moval. At age 26, three years after conceptualizing mi-
crographic surgery, he began treating patients with
cancers of the skin.
In 1936 there was a great deal of skepticism and de-
rision about several aspects of this technique. As men-
tioned earlier, zinc chloride paste had been “black
balled” by mainstream medicine largely because of the
horror stories related to patients who had been treated
at “cancer clinics” in the United States. In addition,
the dogma of that time included the assumption that
cutting through cancers would spread it locally or dis-
seminate it systematically. For this reason, the removal
of cancer “in pieces” as advocated by the Mohs tech-
nique was expected to be ineffective if not dangerous
for the patient. Therefore, in the early years, Dr. Mohs
was only allowed to use his technique on select patients
304 brodland et al.: mohs micrographic surgery
Figure 1. Dr. Mohs and assistants in 1954.
with extremely advanced cancers, which were consid-
ered to be incurable. Despite the presumed hopelessness
of these cases, Dr. Mohs cured most of them.
Founded in a scientific research background, he
kept meticulous records. This data was first reported
in the surgical literature in 19414 and eventually con-
vinced some of the surgical community that his treat-
ment was indeed effective, even in the most difficult
tumors. Despite these early successes and limited ac-
ceptance, the method was still viewed with great sus-
picion predominantly out of ignorance of the tech-
nique in the medical community. It was so different
from the accepted procedure for surgical removal of
neoplasms that when physicians saw the extensive ery-
thema, edema, sloughing, and purulence of the open,
slowly healing, granulating wounds, they felt their suspi-
cions were confirmed. The pain that the patient experi-
enced was another significant detriment to the accep-
tance of this procedure by patients. However, over
time, the combination of the high cure rate and the
surprisingly acceptable results of healing by second in-
tention, the medical community’s impression of this
technique gradually improved. In fact, the impressive
aesthetic results, which were obtained after allowing
wounds to heal by second intention, served as a sort of
reawakening to the usefulness of second intention
wound healing as an acceptable form of closure.
Dr. Mohs was formally trained as a general surgeon
and his initial reports about the technique were aimed
at his general surgery colleagues. In 1946, dermatolo-
gists’ interest in and recognition of the usefulness of
the procedure was inspired by his presentation at the
annual meeting of the American Academy of Derma-
tology in Chicago. The Archives of Dermatology pub-
lished his article on cancer of the face in 1947.5 But it
was the enthusiastic response from the audience to his
lecture to the Dermatology Section of the California
Medical Association that convinced him that the most
Dermatol Surg 26:4:April 2000
interested group of physicians was dermatologists, not
general surgeons.6
Nearly 30 years elapsed after the first use of micro-
scopically controlled surgery before the number of
practitioners of Mohs surgery was sufficient to form an
organization. In 1965, Dr. Mohs met with a group of
12 chemosurgeons and decided that there were enough
practitioners to form an organization. In 1967, at the
International Congress of Dermatology in Munich,
plans were finalized for this organization and a consti-
tution was drawn up. The 1967 annual meeting of the
American Academy of Dermatology in Chicago was
the first official meeting and consisted of 23 attendees
(Figure 2).6
A renaissance in the practicability of Dr. Mohs’
method occurred in 1970 when Dr. Theodore A. Tro-
movitch reported at the American College of Chemosur-
gery meeting his successful results using the fresh tissue
technique.7 This new technique was first used by Dr.
Mohs in 1953 during an unusual break from the tradi-
tional method in order to save time.6 He was making an
instructional film demonstrating the Mohs technique
and was faced with a deadline to complete a multistage
excision of an eyelid basal cell carcinoma in a single day
because they had the camera equipment and crew for
1 day. Dr. Mohs excised the area of residual tumor
under local anesthetic, color-coded the specimen
edges, and created maps in the usual fashion. The only
difference being that frozen sections of fresh tissue
were prepared and examined microscopically in the
same way as the traditional fixed-tissue technique. Be-
cause of the success of the tumor removal and the de-
creased inflammation of the eyelid tissues, Dr. Mohs
frequently used the fresh tissue technique for removal
of eyelid cancers thereafter. In 1969, at the third meet-
ing of the fledgling American College of Chemosur-
gery, he presented a paper on the long-term follow-up
of the fresh tissue technique for eyelid cancers and ex-
tolled its virtues. In this presentation, he reported a
100% five-year cure rate.
Stimulated by the cases that Dr. Mohs presented,
Dr. Tromovitch cautiously began using the “fresh tis-
sue technique” for tumors in other sites.7 Dr. Tromo–
vitch had always felt limited in his ability to perform
Mohs chemosurgery because of the significant pain
that his patients experienced overnight during the pro-
cess of Mohs surgery. It seemed that the highly inflam-
matory nature of the zinc chloride paste, as well as the
duration of the procedure, often lasting for several
days, was the main source of discomfort to his pa-
tients. Dr. Tromovitch reasoned that if Dr. Mohs
could remove a basal cell carcinoma from the eyelid in
a single day without the inflammatory effects of zinc
chloride paste, why couldn’t he remove all skin can-
cers with the fresh tissue technique. At first he was
Dermatol Surg 26:4:April 2000 brodland et al.: mohs micrographic surgery 305

Figure 2. The first formal meeting of the American College of Chemosurgery (ACC) at the 1967 annual AAD meeting in Chicago. Standing
are: (l–r) Milt Eisenstein, John Stopka, John Buckley, Henry Szujewski, Bill Taylor, Tom Jansen, Barry Goldsmith, Jack Latenser, Bill Loney, Bill
Bush, Ellis Mitchell, Victor Witten, Ted Tromovitch, and Perry Robins. Sitting are: (l–r) Dick Moraites, Ray Allington, George Vovruska, Fred
Mohs, Paul Hirsch, Halina Milgram, Jim Brock, Nick Gimbel, and Gerald Peters.

hesitant to use the fresh tissue technique for fear that
it was inferior to the fixed tissue technique. The first
year he treated four patients, who after careful obser-
vation showed no signs of recurrence or other unto-
ward effects. A welcomed side effect of the fresh tissue
technique was that the patients had far less pain and
anxiety related to the procedure. Gradually, as Dr.
Tromovitch became more comfortable with the effec-
tiveness of the procedure, he discontinued the fixed
tissue technique entirely.
His presentation to the College of Chemosurgery
was met with some hostility and skepticism from many
of his colleagues, but the data confirmed that skin can-
cers could be safely and effectively removed using the
fresh tissue technique. It also underscored the fact that
the real reason for the success of the technique was the
microscopic control, not chemical fixation of tissue.
Soon the relative lack of pain compared to the fixed
tissue technique and the fact that most patients could
be treated in 1 day led to the gradual transition of most
Mohs surgeons to the fresh tissue technique. It was
also noticed that even more tissue conservative mar-
gins could be obtained because the depth of tissue ne-
crosis was relatively difficult to control with the fixed
tissue technique. It was not uncommon for the final tis-
sue necrosis to extend substantially deeper than the tis-
sue that was surgically extirpated. In contrast, the fresh
tissue technique resulted in a wound that was only as
extensive as the scalpel created.
The switch to the fresh tissue technique also made it
more practical to treat smaller tumors. Previously
there was a bias that tumors treated by the fixed tech-
nique ought to be large and difficult tumors to justify
the prolonged, arduous technique. Concerns about the
effectiveness of the fresh tissue technique were allayed
as reported cure rates actually improved. These trends
may have resulted from the easier mix that was possi-
ble with the fresh tissue technique.
306 brodland et al.: mohs micrographic surgery
This practical alternative to the original fixed tis-
sue technique, in essence, combined the impeccable
logic of microscopically assisted cancer removal with
a time-efficient technique that included patient conve-
nience and comfort. Another important benefit to the
practitioners of Mohs surgery was that the defect re-
sulting from tissue removal could be more conve-
niently reconstructed. Furthermore, reconstruction
could take place on the same day as the excision.
Prior to the advent of the fresh tissue technique, most
defects, by virtue of the host response to zinc chloride
paste, could not be reconstructed immediately. There-
fore any reconstruction was either delayed or was not
done at all. Quite unexpectedly, the modification in
technique that Dr. Tromovitch championed resulted
in the development of another area of intense inter-
est among dermatologic surgeons, reconstructive sur-
gery.
It was the combination of the practical convenience
of the fresh tissue technique and the allure of the art of
reconstructive surgery that was largely responsible for
the popularization of Mohs surgery. Over the next de-
cade, membership in the American College of Chemo-
surgery rapidly increased to more than 100 members.
Along with this growth in numbers came commensu-
rate growth in the understanding of the potential for
Mohs surgery use as well as the science of cutaneous
oncology. Of course, refinements and technical modi-
fications of the technique have also occurred.
It is said that in 1974, Dr. Daniel Jones, one of Dr.
Mohs trainees, coined the term “micrographic sur-
gery.” This term was used in an attempt to indicate
unambiguously the use of the microscope and the
drawing of maps in order to achieve complete micro-
scopic control of the excision. At the 1985 annual
meeting of the American College of Chemosurgery,
the name of the specialty was changed to Mohs micro-
graphic surgery.
The natural progression and development of this
body of knowledge, now called Mohs micrographic
surgery, was to institute fellowship training require-
ments. This served to ensure a minimum level of train-
ing and experience that Mohs micrographic surgical
fellows received to become eligible for membership in
the major Mohs surgery organization, now known as
the American College of Mohs Micrographic Surgery
and Cutaneous Oncology (ACMMSCO). Until 1983
when the official requirements for Mohs surgery fel-
lowship were enacted, persons seeking training in Mohs
surgery would spend as little as 1 day and up to 1 year
in the practice of an established Mohs surgeon. These
apprenticeships were rotations of varying lengths of
time, during which Dr. Mohs would show visiting phy-
sicians the technique. In 1966, Dr. Perry Robins was
Dermatol Surg 26:4:April 2000
the first Mohs surgeon to establish a 1-year Mohs fel-
lowship training program at NYU. This 1-year fellow-
ship set the precedence for what is now the standard
minimum required duration for the training of Mohs mi-
crographic surgeons as recognized by the ACMMSCO.
Currently there are more than 50 approved fellow-
ships in existence. These fellowships are now reviewed
periodically and are objectively evaluated for the qual-
ity of training they provide.
The efforts of ACMMSCO to standardize and ac-
credit its fellowship programs have done much to im-
prove the specialty, not only through the scientific and
technical advances made by its fellows and program
directors, but also through quality assurance and in
the quantity of training its fellows receive. The ex-
tensive, mentored experience of College-trained Mohs
surgeons distinguishes them from others who perform
microscopically controlled surgery.
There have been many pioneers during the history
of Mohs surgery. It has only been because of the bold,
persistent pioneering efforts of Dr. Mohs and his suc-
cessors that the widespread acceptance of this tech-
nique as the treatment of choice for skin cancers has
occurred. Today the subspecialty of Mohs surgery is
no longer limited to the casual understanding of fro-
zen section histology, cutaneous oncology, minor skin
repairs, and basic dermatology. Rather it has evolved
into a highly refined composite of skills including the
finest and most extensive training in frozen section
dermatopathology. It is unlikely that any other spe-
cialty receives equal experience in frozen section pa-
thology of skin tumors, both in terms of diversity of
diseases and in sheer numbers of histologic sections.
Mohs surgeons are expected, upon graduation from
their fellowships accredited by ACMMSCO, to be ex-
perts in cutaneous oncology, a discipline that is only
peripherally taught in other specialties. Furthermore,
Mohs surgeons are expected to be outstanding recon-
structive surgeons. With a typical Mohs practice per-
forming hundreds to thousands of reconstructions of
cutaneous wounds per year, expertise in cutaneous re-
construction is no longer a convenience or ancillary
part of the practice. They have learned that knowing
when it is best to let wounds heal by second intention
is as important as knowing when to seek the input and
involvement of other physicians in other specialties.
It is only appropriate that this uncompromising ex-
pectation of training and expertise be placed on the
cancers that afflict more Americans than any other.
And, as such, it is appropriate that the expectations
for cure rate, tissue conservation, and excellent aes-
thetic outcomes through appropriate training and ded-
icated focus on the treatment of skin cancer has be-
come the standard of care. In the words of Dr. Mohs,
Dermatol Surg 26:4:April 2000
“It is important that physicians entering the field of
micrographic surgery plan to use the technique seri-
ously and not just occasionally. Increasing numbers of
training programs are available . . . and such training
is advisable.”6
Just as quantum leaps in the care of skin cancer pa-
tients were made with zinc chloride paste and later
with the fresh tissue technique, additional quantum
leaps can be anticipated in the future. As long as there
are those “with a flare for pioneering,” as Dr. Mohs
so aptly stated more than a half century ago, the disci-
pline of Mohs surgery will continue its breathtaking
assault on skin cancer. It is imperative, however, that
just as Dr. Mohs’ original technique was founded in
the research of the zoology laboratory at the Univer-
sity of Wisconsin, we must remain anchored in the sci-
ence of qualitative and quantitative medicine.
Time Line of Important Events
1933 Concept of micrographic chemosurgery is born.
1936 First patients treated.
1941 Dr. Mohs reports success of micrographic sur-
gery in 440 patients.4
1953 Dr. Mohs uses fresh tissue technique for the first
time.
1956 Textbook of Mohs micrographic surgery.
1966 First 1-year fellowship in Mohs surgery (Perry
Robbins at NYU Medical Center).
1968 American College of Chemosurgery founded.
1969 Dr. Mohs presents cases and follow-up of fresh
tissue technique for eyelid tumors.
brodland et al.: mohs micrographic surgery 307
1970 Dr. Tromovitch reports general use of fresh tis-
sue technique.
1974 Term “micrographic surgery” coined.6
1975 Journal of Dermatologic Surgery and Oncology
established.
1983 1-year fellowships established as minimum by
American College of Chemosurgery.
1985 Name of American College of Chemosurgery
changed to American College of Mohs Micro-
graphic Surgery and Cutaneous Oncology
(ACMMSCO).
The term “Mohs micrographic surgery” used in
literature.
1991 Establishment of the American Board of Mohs
Micrographic Surgery and Cutaneous Oncology.
1997 Site visits and fellowship accreditation program
begun by ACMMSCO.
References
1. Mohs FE. Chemosurgery in Cancer, Gangrene and Infections.
Springfield, IL: Charles C. Thomas, 1956.
2. Handley WS. The pathology of melanotic growths in relation to
their operative treatment. Lancet 1907;1:927–33, and 996–1003.
3. Pusey WA. Treatment of malignant growth of the skin from a der-
matologic standpoint. JAMA 1910;66:1611–15.
4. Mohs FE. Chemosurgery: a microscopically controlled method of
cancer excision. Arch Surg 1941;42:279.
5. Mohs FE. Chemosurgical treatment of cancer of the face: a micro-
scopically controlled method of excision. Arch Dermatol Syphilol
1947;56:143.
6. Mohs FE. History of Mohs micrographic surgery. In: Roenigk RK,
Roenigk HH, eds. Dermatologic Surgery: Principles and Practice.
New York: Marcel Dekker, 1989:783–89.
7. Swanson NA, Taylor WB, Tromovitch TA. The evolution of Mohs
surgery. J Dermatol Surg Oncol 1982;8:650–54.
308 brodland et al.: mohs micrographic surgery Dermatol Surg 26:4:April 2000