Is It Okay for a PA to Do Facial Repair After Mohs?

Question

The dermatologist/Mohs surgeon did the surgery, harvested the graft, and left his PA to do the rest. I know that many PA's may be good at stitching. However, I have a hard time comparing a PA to a dermatologist or plastic surgeon. If this is the routine procedure at this office, would I be better off seeking a surgeon who does his/her own stitching on the face? It seems to me to be more intricate than stitching up any other wound. My graft separated and migrated upward after stitches came out.

Ron Shelton, MD · Answer

Although I do not have a P.A. in my office, they certainly could do the sewing of a skin graft. P.A.s have been utilized by plastic surgeons to sew the skin after a facelift is done! Experience is a crucial component of the ability for a P.A. to peform excellent work, and the physician is responsible to supervise their work and is responsible for the outcome.

William Ting, MD · Answer

Defects after Mohs Micrographic Surgery are typically repaired with sutures which involve buried sutures that are meant to provide strength and hold wounds together and self-dissolving followed by top epidermal sutures that are meant to line up wound edges evenly and should be removed 5-14 days depending on location. While some Physician Assistants or Nurse Practitioners may be well-trained and qualified to perform suturing, dermal/buried suturing particularly on the face and neck should be performed by a board-certified physician. The top epidermal sutures are more straight forward and mechanical and can be performed by Physician Assistant or Nurse Practitioner under supervision and discretion of a board-certified physician.

Andrew Kaufman, MD · Answer

It is o.k. for a physician's assistant to do the repair after Mohs surgery,... but only if it's o.k. with you. Some physician's assistants probably do very good work, but I would agree with your comment that it's difficult to compare an MD with a PA. Everybody has preferences as to who should do the repair... plastic surgeon, dermatologist, facial plastic surgeon, etc. My own preference is that I would prefer that a fellowship-trained Mohs surgeon (i.e. from the ACMS) or a fellowship-trained plastic surgeon (i.e. ASPS) do my repair or fellowship-trained oculoplastic surgeon (if it involves the eyelid). So tell the doctor that you would prefer that he or she do the repair next time.

Daniel Berg, MD · Answer

Dermatologists, particularly Mohs surgeons, as well as plastic surgeons have typically both extensive training and experience in all of the issues related to removing a skin cancer surgically and repairing any resulting "defects".  This may add up to years of training and experience, even for young practitioners just beginning.

	It is worthwhile exploring the background, training and experience of any one you choose to allow to do surgery on your face and make sure you are comfortable with the answers.

Kavita Mariwalla, MD · Answer

221641 anon, A Mohs surgeon is responsible for the surgical removal of tumor and the interpretation of slides to ensure complete margin control. It is possible for other surgeons to perform the repair however if you are going to a Mohs surgeon, you typically expect them to be the ones doing the stitching. While grafts can be placed by a PA, there is some finesse that take place in sewing them precisely into place. I do not have any PAs employed in my practice. The key thing is that if it makes you feel uncomfortable, I would simply request the surgeon that he/she do the entire procedure. Good luck, Dr. Mariwalla

Steven Hacker, MD · Answer

In my practice, I do not have a PA treat any patient with cancer. This approach is individualized not standardized. If your surgeon has confidence in his or her PA and you have confidence in your surgeon, then that is the key issue.

Brent Spencer, MD · Answer

The PA may do a fine job at your repair, but I would never let a PA do repairs in my office.   The level of training is just not there.  Now there may be some PAs out there that do good work, but I know that they do not get a lot of training in suturing in their training programs (disclosure:  my wife is a PA). 

	In my opinion, I would find someone who does the sewing his/herself.  If the doctor is delegating a task as important as facial reconstruction to a midlevel provider, he/she is probably doing it for the financial compensation and not for the good of patient care. 

	Again, this is all my personal opinion, but facial repairs need to be left to MDs.

Is It Okay for a PA to Do Facial Repair After Mohs?

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