Floaters in mohs micrographic surgery

Murad Alam, Anjali D. Shah, Sana Ali, Mutahir Rauf, Michael Nodzenski, Omer Ibrahim, Jillian H. Swary, Emily Poon, Sumaira Aasi, Ashish Bhatia, Hayes Gladstone, Steven Goulder, Vivek Iyengar, Nanette J. Liégeois, Kishwer S. Nehal, Marie Tudisco, Ryan W. Ahern, John G. Albertini, Anne Chapas, David CowanMontgomery Gillard, Hubert T. Greenway, Ashraf M. Hassanein, Nathaniel J. Jellinek, Jeremy Kampp, John D. Kayal, Ravi S. Krishnan, Erick A. Mafong, Ronald M. Mann, Isaac M. Neuhaus, Désireé Ratner, Ally Khan Somani, Emily P. Tierney, Robert S. Tomsick, Summer Youker, Natalie Kim, Simon Yoo

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Background: Floaters are dislodged pieces of tumor tissue than can obscure Mohs micrographic surgery (MMS) frozen sections and confound their interpretation. Objective: To understand the common causes of floaters and identify management strategies. Methods: An initial virtual consensus conference of Mohs surgeons based on a 60-item questionnaire. Data were validated in interviews with randomly selected Mohs surgeons. Results: Based on retrospective reporting of 230 surgeon-years and 170,404 cases of MMS by 26 surgeons, the mean rate of floaters per tumor treated was 1.8%, and the rate of floaters per tissue block was 0.70%. Not wiping blades between cuts when a stage is separated into subunits can predispose to floaters. There was also strong consensus that basal cell carcinomas, ulcerated tumors, and tissue from the first stage were more likely to yield floaters. There is little consensus on how to manage floaters, with possibilities including taking additional sections, taking an additional stage, or simply noting the floater. Conclusion: Floaters are not rare and can complicate MMS margin assessment. There is significant expert consensus regarding the causes of floaters and the tissue features that may predispose to them. Floaters may be prevented by minimizing their likely causes. There is less consensus on what to do with a floater.

Original languageEnglish
Pages (from-to)1317-1322
Number of pages6
JournalDermatologic Surgery
Issue number9
StatePublished - Sep 2013
Externally publishedYes


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