The Use of 3D Printed Models in Mohs Micrographic Surgery
Phase: NA
Conditions: Mohs Micrographic Surgery
Sponsor: Case Comprehensive Cancer Center

 
Study Number: CASE 6617 
Study Title: The Use of 3D Printed Models in Mohs Micrographic Surgery 
 
Principal Investigators: 
Dr. Daniel Popkin, MD, PhD. 
University Hospitals Department of Dermatology, 11100 Euclid Ave, Cleveland, OH 44106 
Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106  
216-368-0237 / dxp214@case.edu 
 
Margaret Mann, MD 
University Hospitals Department of Dermatology, 11100 Euclid Ave, Cleveland, OH 44106 
Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106 
216-844-8200 / Margaret.Mann@uhhospitals.org 
 
Statistician:    
Pingfu Fu, PhD  
Biostatistician & Associate Professor,  
Department of Population and Quantitative Health Sciences 
Case Western Reserve University School of Medicine Avenue, 2109 Adelbert Road, Cleveland OH 
216-368-3911 / pxf16@case.edu  
 
Research Personnel: 
Mary Consolo 
University Hospitals Department of Dermatology, 11100 Euclid Ave, Cleveland, OH 44106 
Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106 
Mary.Consolo@uhhospitals.org 
 
Erich Zirzow 
University Hospitals Department of Dermatology, 11100 Euclid Ave, Cleveland, OH 44106 
Erich.Zirzow@uhhospitals.org 
 
Mark Biro 
University Hospitals Department of Dermatology, 11100 Euclid Ave, Cleveland, OH 44106 
Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106 
Mxb638@case.edu 
 
Study Site(s): University Hospitals Main Campus, University Hospitals Westlake Campus, 
University Hospitals Chagrin Highlands Campus 
Protocol Version:  (1.2) 3/2/2018 
Sponsor: Case Comprehensive Cancer Center 
Funding Sponsor: National Institute of Health Grant ID T32 AR007569 

 
 
 
 
 
TABLE OF CONTENTS 
 
1.0 INTRODUCTION ....................................................................................................................... 1   
  
1.1 Overview ................................................................................................................................ 1  
  
1.2 Background and Rationale ..................................................................................................... 1  
 
2.0 OBJECTIVES .............................................................................................................................. 2  
 
3.0 RESEARCH SUBJECT SELECTION ....................................................................................... 2  
 
4.0 RESEARCH SUBJECT ENTRY ................................................................................................ 2  
 
5.0 STUDY DESIGN AND METHODS ....................................................................................... 2-5  
  
5.1 Design/Study Type ................................................................................................................. 3   
  
5.2 Selection of Instruments...................................................................................................... 3-4   
  
5.3 Description of Intervention .................................................................................................... 4   
  
5.4 Data Collection ....................................................................................................................... 4   
  
5.5 Description of Study Process .............................................................................................. 4-5  
 
6.0  STATISTICAL ANALYSIS .................................................................................................... 5-7  
 
7.0  REFERENCES ......................................................................................................................10-11  
 
8.0 APPENDICES .......................................................................................................................12-18  
 
 
 

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INTRODUCTION 
 
1.1 Overview 
Perioperative anxiety in Mohs Micrographic Surgery (MMS) is associated with increased post-
operative pain and decreased patient satisfaction. Optimum delivery of patient education has been 
suggested as a potential modality to decrease perioperative anxiety, but has not been conclusively 
demonstrated. A pilot study completed in July 2017 at University Hospital’s Westlake Campus 
demonstrated that patient education completed with a 3D printed model and standardized script 
increased patients subjective understanding and decreased patient anxiety during the perioperative 
period. Despite these findings, the pilot study had notable limitations that included a small sample 
size and lacked an adequate control group. Our aim is to complete a comprehensive randomized 
control trial, with a larger cohort of patients and an adequate control group, to compare of our 
innovative counseling protocol to the current standard of care, verbal counseling. This work may 
help to provide an optimized educational delivery system for MMS at University Hospitals. 
 
1.2 Background and Rationale 
Non-melanoma skin cancer is frequently treated with MMS in the clinical setting. This procedure 
is completed under local anesthesia and the goals of treatment include complete removal of the 
cancer, perseveration of normal skin function and to provide patients an optimal cosmetic result. 
Cure rates of MMS have been cited above 95% for BCC & SCC.1-3, 6 
  
In previous studies, increased perioperative anxiety was associated with increased postoperative 
pain and decreased patient satisfaction.3-7 Prior literature has demonstrated efficacy of 
personalized intraoperative music and midazolam treatment to reduce perioperative patient anxiety 
in MMS.3-11 It has been suggested that optimized delivery of patient education may be effective in 
decreasing patient anxiety, however, it has not been demonstrated. 
  
The use of physical models, often created with 3D printing technology, have been effective in the 
delivery of medical education for patients, medical students and medical residents. In fact, most 
studies demonstrate that physical models outperform static (2D) or dynamic (3D), animated or 
digitized, representations for the delivery of medical education.12-18 In addition, the use of physical 
models for the delivery of medical education has been shown to decrease learner anxiety.12,19 
 
In July 2017, a pilot study was completed in the University Hospitals Westlake MMS Clinic to 
determine if a 3D printed MMS model and standardized script protocol could enhance patient 
understanding of MMS and decrease perioperative patient anxiety.19 This pilot study included 25 
patients and demonstrated that explanation with a 3D printed MMS model and standardized script 
patients had a statistically significant increase in understanding of MMS by 1.5 points and decrease 
in anxiety by 1.5 points using a Visual Analog Scale.19 Limitations of our initial study included 
lack of an adequate control group and small initial sample size.  
 
Our aim is to complete a comprehensive randomized control trial, with a larger cohort of patients 
and adequate control group to investigate the effectiveness of our innovative counseling protocol 
featuring a standardized script and 3D printed MMS model. 
 
 

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2.0 OBJECTIVES 
1. To investigate if patient education with a 3DP MMS model and standardized script 
protocol increases patient understanding of MMS more than current standard of care 
(control group) at the University Hospitals Cleveland Medical Center MMS Clinics.  
 
2. To investigate if patient education with a 3DP MMS model and standardized script 
protocol decreases perioperative patient anxiety during MMS more than current standard 
of care (control group) at the University Hospitals Cleveland Medical Center MMS 
Clinics.  
 
3. To evaluate if patient satisfaction with a 3DP MMS model and standardized script 
protocol increases patient satisfaction during MMS more than current standard of care 
(control group) at the University Hospitals Cleveland Medical Center MMS Clinics.  
 
3.0 RESEARCH SUBJECT SELECTION AND ELIGIBILITY 
A total of 100 subjects between the ages of 18-90 years old, who are undergoing Mohs 
Micrographic Surgery at University Hospitals Cleveland Medical Center, Chagrin Highlands and 
Westlake Campus will be considered for the study. Patients will not be provided compensation 
for participation. 
 
Eligible participants must be capable of reading and completing all subjective questionnaires 
including the State-Trait Anxiety Inventory (STAI), Visual Analog Scale (VAS), Post-
Intervention Knowledge Survey and Satisfaction Survey. Patients will be ineligible for the study 
if they choose not to participate, or cannot complete the subjective or objective questionnaires 
described above. 
 
4.0 
RESEARCH SUBJECT ENTRY 
Subjects will be recruited voluntarily from the University Hospitals Department of Dermatology 
Mohs Microsurgery Clinics. All patients who meet inclusion criteria will be eligible for the study. 
Patients will be randomized into experimental or control groups prior to onset of study protocol. All 
patients will undergo verbal consent in private patient rooms prior to the onset of the study protocol 
and will have the option to withdraw from the study at any time throughout the study. Verbal consent 
is preferred to written consent to prevent the collection of information classified as protected health 
information (PHI).  
 
5.0 STUDY DESIGN AND METHODS 
A total of 100 patients will be recruited from University Hospitals Department of Dermatology 
Mohs Micrographic Surgery Clinics at the Cleveland Medical Center, Chagrin Highlands and 
Westlake Locations. These patients will be randomly assigned to a control (50%) or experimental 
group (50%) prior to the onset of the study protocol. Patients in the control group will be educated 
on MMS according to the current standard of care, verbal counselling, with a standardized script 
(Appendix A). The experimental group will be educated on MMS with a standardized script in 
addition to a 3D MMS model (Appendix B). 
 
Patients will initially undergo verbal consent in private patient rooms located within the Mohs 
Microsurgery Clinics prior to study initiation. As previously stated, verbal consent will prevent the 

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collection of any PHI during this study. Upon verbal consent, patients will fill out baseline testing 
including a State-Trait Anxiety Inventory (STAI) and Visual Analog Scale (VAS) to quantify 
their anxiety and understanding of the Mohs procedure (Appendices C, D, E). Following baseline 
testing, patients will undergo preoperative education. In the control group patients will be 
educated with a standardized script alone, and experimental group patients with a standardized 
script, in addition to a 3DP physical model demonstrating the MMS procedure. The total length 
of time to educate patients will be recorded.  
 
After completion, patients will undergo standard of care procedures with the MMS team, 
including surgeon, and undergo the first stage of the MMS procedure. Patients will undergo post-
testing following the first layer of MMS. This layout was chosen to ensure all patients to prevent 
study personnel from impeding the workflow of the MMS clinic, and is similar to a workflow 
used in previous studies.4,5  
 
Once complete, patients in both groups will fill out a post-intervention STAI, a VAS for anxiety 
and level of understanding of the Mohs Procedure. In addition, patients will receive an objective 
Mohs Quiz and subjective Satisfaction Survey (Appendices F, G). All of the data collected for 
the study will be de-identified, HIPPA-compliant and encrypted on a password protected 
Department of Dermatology server folder.  These secure file folders are restricted and only 
research personnel have access to the files. In addition to de-identification, encryption and 
password protection, these data are also protected by University Hospitals firewall as well. 
 
5.1 Design/Study Type  
We propose a randomized control group format with 50% of patients randomized to the control 
limb and 50% of patients randomized to the experimental group. 
 
5.2 Selection of Instruments 
Pre-intervention and Post-intervention instruments 
1) State-Trait Anxiety Inventory (STAI) 
a. The STAI is a well-known, frequently used measure of patient anxiety within the 
clinical setting.5,8 This form consists of two forms to assess state anxiety and a 
patient’s baseline trait anxiety. Each form consists of 20 Likert-type questions that 
can be easily answered by a patient with an average reading level. Estimated time 
for completion of these questions is approximately 2 minutes per form. This form 
has been used in 2 studies to date that assess intraoperative anxiety in Mohs.5,8 
b. We plan to use the anxiety State Form Y1, appendix A, at baseline and following 
completion of Stage 1 of MMS. 
c. We plan to use the anxiety Trait Form Y2, appendix B, at baseline only to compare 
the baseline level of anxiety between the control and experimental groups. 
d. Found in Appendices C, D 
 
2) Visual Analog Scale (VAS) 
a. The VAS is a frequently employed Likert-type scale that is used to measure 
anxiety.5,8 This 0-10 scale documents the patients current state of anxiety and can 
be answered by patients with an average reading level. Estimated time of 
completion is under 30 seconds. This form has been used in 2 studies to date and 

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previously by experimental team to assess intraoperative anxiety in Mohs. 5,8,19 
b. In addition, because of the ease of use this tool has been converted to assess other 
objective measures including understanding. This was previously used by our 
experimental team to quantify patient’s understanding of MMS.19 
c. We propose to use the VAS for anxiety and understanding at baseline and following 
completion of the first stage of MMS.  
d. Found in Appendix E 
3) Objective Questionnaire & Patient Satisfaction Survey  
a. We have designed a short, questionnaire with 6 objective questions related to the 
patient’s understanding of Mohs. This objective portion is to help to delineate 
objective differences in understanding between the control and experimental 
groups. This testing was created under the guidance of Dr. Margaret Mann (Mohs 
Surgeon) and similar objective surveys have been used to assess understanding 
following educational intervention.12-18 Our estimate is that this short quiz will take 
approximately 3 minutes for patients to complete. 
b. Following the objective questions, patients will be provided 3 subjective questions 
related to their satisfaction with the explanation of MMS that they received. These 
subjective questions will be used to help delineate subjective differences between 
the control and experimental groups. Similar objective surveys have been used to 
assess satisfaction following educational intervention.12-18 
c. We propose to hand out this questionnaire following completion of the first stage 
of MMS.  
d. See Appendix F & G 
 
5.3 Description of Intervention 
A standardized script including the counselling that patients would receive in both the control and 
experimental groups is included in the attached study documents. See Appendix A, B. This will 
allow for patients to receive the same information throughout the study, similarly to our recently 
completed pilot study.19 Patients in the experimental group will be educated with our 3D printed 
MMS model, in addition to the standardized script.  
 
5.4 Data Collection 
 
The same data will be collected from both groups of patients. This information will not include any 
data regarded as protected health information. 
 
Data 
At Baseline 
Following Stage 1 of MMS 
Age (excluding birthdate) 
X 
 
Gender 
X 
 
Subjective Response to “Previous 
History of Mohs” 
X 
 
STAI Form Y-1 
X 
X 
STAI Form Y-2 
X 
 
VAS Anxiety 
X 
X 
VAS Understanding of Mohs 
X 
X 
Mohs Quiz   
 
X 
Satisfaction Survey 
 
X 

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5.5 Description of Study Process 
5.51 Instrument Administration  
The instruments provided are self-administered questionnaires. Patients will be handed these 
questionnaires in private rooms during the study and will be supervised by the research team. 
Patients will be told about the instruments prior to administration of each questionnaire. Patients 
will be given adequate time to complete each questionnaire provided. 
 
5.52 Intervention Administration 
The educational intervention will be completed following baseline testing by the research assistant 
in a private patient room according to the standardized script. If patients have additional questions 
regarding the study at the time of intervention they will be answered by the research assistant. If 
these questions pertain to the patients’ medical record, protected health information, or specific 
medical questions related to their MMS procedure the research assistant will defer to the medical 
team. Patients will receive educational intervention following baseline testing.  
 
5.53 Special Concerns 
If patients would not like to complete the study they can inform the research team at any time and 
there will be a discontinuation of all study procedures.  
 
5.54 Compensation 
Patients will not be compensated for participating in this study. 
 
5.55 Adverse Reactions and Their Management 
 
5.56 Reporting Adverse Events 
No adverse events are expected.  
 
5.57 Anticipated Reactions 
No reactions are anticipated. 
 
5.58 Reaction Management 
If patients experience additional stress, discomfort, anxiety or other reactions to questionnaires the 
study can be ended at any time if the patient informs the research personnel. 
 
6.0 STATISTICAL ANALYSIS 
6.1  
All patients will complete the study protocol on the day of their Mohs procedure. Patients will 
conclude the study protocol following administration of post-stage testing. Following conclusion, 
patients will undergo the remainder of their Mohs procedure according to standard of care. 
 
6.2  
Several instruments will be used during the study to detect differences between the control and 
experimental group. Our power analysis was designed to determine the number of patients per 
group required to determine a difference between the control and experimental group’s results of 
the STAI Form Y1 (Appendix A). This form detects the differences in patient’s current state of 

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anxiety at the time of completion. This form consists of 20 questions, with each question worth 
between 1-4 points, with patients at minimum scoring 20 to indicate a minimum level of anxiety 
and 80 to indicate a maximum state of anxiety. Our aim is to detect a minimum difference in the 
STAI Form Y1 of 5 points between the control and experimental groups.  
 
Based on data from prior studies5, we anticipate that the mean STAI score will be approximately 
38.7 +/- 10. We anticipate that a 6 point difference between the experimental and control groups 
would represent statistical significance. Considering these constrains sample size analysis was 
done to determine the number of patients needed to detect a 6 point difference, with a standard 
deviation of approximately 10, significance set to .05 and power of 80%. Within these constraints 
we estimate approximately 45 patients would be needed per group using 2-sided T-test (nQuery 
Advisor). Assuming a rate of 10% attrition per every 100 patients, we estimate we will need 
approximately 50 patients per group during the study. 
 
In a prior pilot study, approximately 7 patients were enrolled per MMS clinic. Based on estimates 
from this study, we anticipate that it will take approximately 12-20 MMS clinics to recruit patients 
for this intended study. Clinics are held on average 2 days per week, and thus we anticipate 
completion from 3-5 months from the beginning of the study. 
 
6.3  
In subgroup analysis patients will be stratified based on age, gender, and prior experience with MMS 
or not. We anticipate that patients who have previously undergone MMS will have lower anxiety 
scores across all measures and increased understanding of the procedure, based on the results of our 
pilot study. This is anticipated based on the results of the previous pilot study and other literature.5  
 
Patients will be randomly selected according to day of the study, every other day randomization. We 
anticipate that there will be no significant differences between groups based on age, gender and prior 
experience with MMS based on randomization protocol. All patients from a given clinic will be 
allocated to the control or experimental group prior to onset of the day. 
 
6.5  
If patients are unable to be complete the experimental protocol, their data will be discarded prior to 
final analysis. Patients may drop out from the study at any time, according to the guidelines of the 
protocol. This will not impact outcome of their procedure. 
 
6.6  
Ineligible patients for the study fall under one or more of the below criteria: 
• Under 18 years of age 
• Over 90 years of age 
• Cannot complete the survey measures independently for any reason 
 
6.7  
Statistical analyses for this randomized control trial will be completed under the supervision Dr. 
Pingfu Fu, Dr. Margaret Mann and Dr. Daniel Popkin. This analysis will use basic statistical 
measurements in order to determine differences between the control and experimental groups. 
Demographic information including age (but excluding birth date), gender and response to prior 

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MMS treatment will be compared between control and experimental groups. STAI, VAS, 
Objective Questionnaire and Patient Satisfaction Questionnaire responses will be recorded and 
results including median and mean data will be determined. Pre- and post-surgery measurements 
will be compared using paired T-test. To compare experimental and control groups, T-test will be 
used after checking normality assumption. In addition, to compare subgroups of the experimental 
and control groups (> 2 groups) ANOVA followed by Tukey pairwise procedure will be used. If 
normality assumption is violated, Wilcoxon rank signed test and Kruskal-Wallis test will be used. 
  
6.8 
In patients who did not complete the experimental protocol, data would be discarded as stated 
previously. If a complete dataset were to be lost for a patient whom completed the entire protocol, 
data would be handled according to the digression of the study team. In patients missing only one 
value, median data point would be applied. If patients were missing one or more values, data would 
need to be discarded. 
 
 

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7.0 REFERENCES 
1. Lear JT, Harvey I, De berker D, Strange RC, Fryer AA. Basal cell carcinoma. British 
Medical Journal. 2003;327:794-798. 
2. Connolly KL, Nehal KS, Disa JJ. Evidence-Based Medicine: Cutaneous Facial 
Malignancies: Nonmelanoma Skin Cancer. Plastic and Reconstructive Surgery. 
2017;139(1):181e-190e. 
3. Chen AF, Landy DC, Kumetz E, Smith G, Weiss E, Saleeby ER. Prediction of 
postoperative pain after Mohs micrographic surgery with 2 validated pain anxiety 
scales. Dermatologic Surgery. 2015;41(1):40-7. 
4. Persichetti GB, Walling HW, Ceilley RI. Personalized music enhances patient 
perception of the Mohs surgery experience. Dermatologic Surgery. 2009;35(2):265-7. 
5. Vachiramon V, Sobanko JF, Rattanaumpawan P, Miller CJ. Music reduces patient 
anxiety during Mohs surgery: an open-label randomized controlled trial. 
Dermatologic Surgery. 2013; 39(2):298-305. 
6. Zbar RI. Identifying and managing those patients at risk for aborted mohs 
micrographic surgery. Annals of Plastic Surgery. 2012;68(1):67-71. 
7. Ravitskiy L, Phillips PK, Roenigk RK, et al. The use of oral midazolam for 
perioperative anxiolysis of healthy patients undergoing Mohs surgery: conclusions 
from randomized controlled and prospective studies. Journal of the American 
Academy Dermatology. 2011;64(2):310-22. 
8. Sobanko, Joseph F. et al. Preoperative telephone consultation does not decrease 
patient anxiety before Mohs micrographic surgery. Journal of the American Academy 
of Dermatology. 2017;76(3)519-526. 
9. Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative 
multimedia information on perioperative anxiety in patients undergoing procedures 
under regional anaesthesia. British Journal of Anaesthesia. 2010;104(3):369-374. 
doi:10.1093/bja/aeq002. 
10. Love EM, Manalo IF, Chen SC, Chen K-H, Stoff BK. A video-based educational 
pilot for basal cell carcinoma (BCC) treatment: A randomized controlled 
trial. Journal of the American Academy of Dermatology. 2016;74(3). 
doi:10.1016/j.jaad.2015.10.014. 
11. Migden M, Chavez-Frazier A, Nguyen T. The Use of High Definition Video Modules 
for Delivery of Informed Consent and Wound Care Education in the Mohs Surgery 
Unit. Seminars in Cutaneous Medicine and Surgery. 2008;27(1):89-93. 
doi:10.1016/j.sder.2008.02.001. 
12. Tsai A, Barnewolt CE, Prabhu SP, et al. Erratum to “Creation and Validation of a 
Simulator for Neonatal Brain Ultrasonography: A Pilot Study”. Academic Radiology. 
2017. doi:10.1016/j.acra.2017.04.002. 
13. Preece D, Williams SB, Lam R, Weller R. 2013. “Let’s Get Physical”: Advantages of 
a physical model over 3D computer models and textbooks in learning imaging 
anatomy. Anat Sci Educ 6:216–224. 
14. Khot Z, Quinlan K, Norman GR, Wainman B. 2013. The relative effectiveness of 
computer-based and traditional resources for education in anatomy. Anat Sci Educ 
6:211–215. 
15. Li Z, Li Z, Xu R, et al. Three-dimensional printing models improve understanding of 
spinal fracture-A randomized controlled study in China. Sci Rep. 2015;5(11570):1-9. 

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16. Lim KH, Loo ZY, Goldie SJ, Adams JW, McMenamin PG. Use of 3D printed models 
in medical education: A randomized control trial comparing 3D prints versus 
cadaveric materials for learning external cardiac anatomy. Anat Sci Educ. 
2016;9(3):213–221. 
17. O’Reilly MK, Reese S, Herlihy T, et al. Fabrication and assessment of 3D printed 
anatomical models of the lower limb for anatomical teaching and femoral vessel 
access training in medicine. Anat Sci Educ. 2016;9(1):71–79. 
18. Biglino G, Capelli C, Wray J, et al. 3D-manufactured patient-specific models of 
congenital heart defects for communication in clinical practice: feasibility and 
acceptability. BMJ Open. 2015;5(4):e007165.k 
19. Biro, M., Mann M, Popkin D. / Biro M.. (April, 2017). The Use of 3D Printed Models 
to Optimize Patient Education in Mohs Micrographic Surgery Poster presented at: 
Ohio Dermatological Association Annual Meeting; Columbus, OH, USA. 
 
 
 
 
 
 
 
 

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8.0 APPENDICES 
File 
Appendix ID 
1) Standardized Script 
A 
2) 3D Printed Mohs Micrographic 
Surgery Model 
B 
3) STAI Form Y1 
C 
4) STAI Form Y2 
D  
5) VAS Anxiety & Understanding 
E 
6) Mohs Quiz  
F 
7) Satisfaction Survey 
G 
 
 
 

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Appendix A - Standardized Script 
 
What is Skin Cancer? 
Skin cancer is the most common form of cancer and over one million people in the United States 
develop skin cancer per year. The majority of these skin cancers are either called either basal cell 
carcinoma (BCC), or squamous cell carcinoma (SCC), based on the cell type the cancer 
originates from.  
 
Patients will either then be counseled using ¶1 – for BCC    ¶2 – for SCC 
¶1 - for BCC: This is the most common skin cancer and almost never spreads, therefore it is 
very rarely life threatening. This type of tumor can be very locally destructive and can become 
problematic when it involves structures on the face and neck. As they increase in size, they 
become more complex to remove and have the potential to invade into bone and other tissues. 
 
¶2 - for SCC: This is the second most common form of skin cancer and has the potential to be 
aggressive, but usually only once they reached a size over 2 cm in diameter.  With this tumor 
type there is concern for invasion into the surrounding tissue, which is why prompt removal of 
this type of skin cancer is recommended.  
 
These tumors are commonly described by patients as the “pimple that does not go away” or 
“scab that just won’t heal” prior to seeking care from a dermatologist. Often times the tumor has 
been growing for several months to years, prior to recognition by patients and treatment. 
Although a skin cancer may appear small from the surface, in many cases the cancer undergoes 
extensive growth below the skin, former, deeper root-like branching patterns and thus the visible 
tumor maybe only represent the “tip of the iceberg.” 
 
Why people get skin cancer? 
Long-term exposure to sunlight, especially during the teenage years and early adult decades, is 
the single most important factor in the formation of skin cancer. After years of ultraviolet light 
damage to sun-exposed areas, normal skin cells may transform into cancer cells. As a collective 
group, these cells will divide more rapidly than the surrounding skin cells, until they become 
readily visible to patients and dermatologists as a skin cancer. 
 
What are the treatment options for skin cancer? 
Depending on the specific characteristics of your skin cancer, a number of different treatments 
can be used. These treatments include excision of the tumor, curettage and electrodessication, 
and Mohs Surgery.  
 
What is Mohs Micrographic Surgery? 
Mohs micrographic surgery is the gold treatment of choice in basal and squamous cell 
carcinoma, when they become large in size and/or effect important functional areas like the head 
and neck. The goals of this procedure are to completely remove the cancer, preserve normal skin 
function and are to provide an optimal cosmetic result. Overall, this treatment has a 97-99% cure 
rate for skin cancer. 
  
The Mohs Procedure 

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The Mohs procedure entails a series of repeated “stages” to ensure complete cancer removal. 
During each stage, a layer of tissue is removed, processed and examined under the microscope to 
determine if any residual cancer remains.  
 
Before the Mohs procedure, an area surrounding the skin cancer will be numbed with local 
anesthetic. Once numbed, a thin, “saucer-shaped” layer of tissue is removed. A small portion of 
healthy tissue around the skin cancer is taken, in attempt to clear the tumor during the first stage 
of the procedure. This takes approximately 5 minutes, after which time your wound will be 
bandaged. 
 
Figure 1: Left: Demonstrates the irregular appearance of skin cancer compared to healthy tissue. Middle: Demonstrates an example of the first 
layer of tissue take during MMS with residual tumor tissue. Right: Demonstrates the residual tumor embedded in the surrounding tissue. 
*Figures included for IRB review board only, demonstrate how models will be used. For more information see supplemental document 
 
The tissue specimen is then taken to the lab, marked and processed. Using a map of the cancer 
cells in relation to the healthy tissue, the surgeon can determine during microscopic examination 
if there are remaining cancer cells. The entire stage takes about 1 hour. Approximately half of 
patients will need additional stages during the procedure. These stages are completed in a similar 
manner, which will increase the time needed to complete the procedure.  
 
Following complete removal of the cancer, your surgeon will determine the best method to treat 
your wound. Options include allowing the wound to heal naturally, using stiches to sew the 
wound closed, using a skin grafting to cover the surgical wound, or by using a flap procedure to 
close the wound. This will be discussed more extensively with your surgeon during the 
procedure, based on the size and location of your skin cancer.  
 
What are the advantages of Mohs? 
The major advantages to Mohs Surgery are that this procedure has the highest cure rate for skin 
cancer, removes a minimal amount of healthy tissue, provides the opportunity to achieve an 
optimal cosmetic outcome with minimal scarring, and eliminates the need for general anesthesia 
or hospitalization.  
 
What are the risks of Mohs? 
The risks of surgery, as with any trauma to the skin, risks include bleeding, bruising around the 
surgical area, a risk of infection below 1% and local numbness. In addition, there is often a need 
to extend surgical incisions approximately 3 times the length of the initial incision to facilitate 
optimal closure of the surgical wound. Again, these risks are shared by excisional procedures, 
whether MMS or non-MMS. 
 

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Appendix B 
3D Printed Mohs Micrographic Surgery Model 
Images of 3D printed MMS model 
 
 
 

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Appendix C 
 
 
Please provide the following information: 
 
Age  
 
Previous Mohs (Circle) Y N 
Gender (Circle) M F 
DIRECTIONS: 
A number of statements which people have used to describe themselves are given below. 
Read each statement and then blacken the appropriate circle to the right of the statement to 
indicate how you feel right now, that is, at this moment. There are no right or wrong 
answers. Do not spend too much time on any one statement but give the answer which seems 
to describe your present feelings best. 
 
 
1 
I feel calm 
1 
2 
3 
4 
2
I feel secure
1
2
3
4
3 
I am tense 
1 
2 
3 
4 
4 
I feel strained 
1 
2 
3 
4 
5 
I feel at ease 
1 
2 
3 
4 
6
I feel upset
1
2
3
4
7 
I am presently worrying over possible misfortunes 
1 
2 
3 
4 
8 
I feel satisfied
1 
2 
3 
4 
9 
I feel frightened 
1 
2 
3 
4 
10
I feel comfortable
1
2
3
4
11 
I feel self-confident 
1 
2 
3 
4 
12 
I feel nervous 
1 
2 
3 
4 
13 
I am jittery 
1 
2 
3 
4 
14 
I feel indecisive 
1 
2 
3 
4 
15 
I am relaxed 
1 
2 
3 
4 
16 
I feel content 
1 
2 
3 
4 
17 
I am worried
1 
2 
3 
4 
18 
I feel confused 
1 
2 
3 
4 
19 
I feel steady 
1 
2 
3 
4 
20 
I feel pleasant 
1 
2 
3 
4 
SELF-EVALUATION QUESTIONNAIRE 
STAI AD Form Y-1 

Appendix D 
 
DIRECTIONS: 
A number of statements which people have used to describe themselves are given below. Read 
each statement and then blacken in the appropriate circle to the right of the statement to indicate 
you generally feel. 
21 I feel pleasant 
1 2 3 4 
22 I feel nervous and restless 
1 2 3 4 
23 I feel satisfied with myself 
1 2 3 4 
24 I wish I could be as happy as others seem to be 
1 2 3 4 
25 I feel like a failure
1 2 3 4 
26 I feel rested 
1 2 3 4 
27 I am “calm, cool, and collected” 
1 2 3 4 
28 I feel that difficulties are piling up so that I cannot overcome them 
1 2 3 4 
29 I worry too much over something that really doesn’t matter 
1 2 3 4 
30 I am happy 
1 2 3 4 
31 I have disturbing thoughts 
1 2 3 4 
32 I lack self-confidence 
1 2 3 4 
33 I feel secure 
1 2 3 4 
34 I make decisions easily 
1 2 3 4 
35
I feel inadequate
1
2
3
4
36 I am content 
1 2 3 4 
37 Some unimportant thought runs through my mind and bothers me 
1 2 3 4 
38 I take disappointments so keenly that I can’t put them out of my mind 
1 2 3 4 
39 I am a steady person 
1 2 3 4 
40 I get in a state of tension or turmoil as I think over my recent concerns 
and interests 
1 2 3 4 
SELF-EVALUATION QUESTIONNAIRE 
STAI AD Form Y-2 

CASE Models in Mohs 11/2/2017  
 
16
Appendix E 
VAS Patient Anxiety 
 
VAS Patient Understanding of Mohs 
 

CASE Models in Mohs 11/2/2017  
 
 
17
Appendix F 
 
Mohs Quiz 
Thank you for your participation in our study! We ask you to fill out the quiz and choose the best answer 
for each question. Do not worry about your score, as you cannot fail.  
 
1. What are the main benefits of the Mohs procedure compared to other treatments? 
A) The procedure is faster 
B) The procedure allows for easier repair of the wound 
C) The recovery time is faster 
D) Mohs removes the entire cancer in one procedure and has a higher cure rate.  
 
2. How is the cancer removed in the first stage of the Mohs procedure?  
 
3. How can my doctor be sure that all cancer cells are removed? 
A) You will find out your results in one week after a pathologist views the specimen 
B) A special dye is added that “light’s up” in cancer cells 
C) Based on the size of the visible tumor 
D) Your doctor examines the skin under the microscope and maps out any remaining cancer 
 
4. Do all patients require a second stage of cancer removal? 
A) No, a second stage is not necessary if all of the cancer was removed 
B) Yes, a second stage is always removed to help close the surgical wound 
C) No, the Mohs procedure is completed in one layer always 
D) Yes, a few extra millimeters of extra healthy tissue are always removed 
 
5. What are the reasons for a layer-by-layer approach when removing the cancer? 
A) To ensure that the surgical wound can be closed easily 
B) To remove a minimal amount of healthy skin, while removing the whole cancer 
C) There is less bleeding with this approach 
D) To prevent infection 
 
6. Why do Mohs surgeons remove an area of healthy skin around the cancer? 
A) To try to remove all of the cancer in one stage 
B) The visible portion of the cancer is the only portion of the cancer that matters 
C) None of the skin surrounding the cancer is “healthy” 
D) The skin is going to die because it is so close to the cancer 
A 
B 
D 
C 

CASE Models in Mohs 11/2/2017  
 
 
18
Appendix G 
 
Satisfaction Survey 
 
1. Overall how satisfied are you with today’s explanation of the Mohs Procedure? 
A) Not at All Satisfied 
B) Somewhat Satisfied 
C) Neutral 
D) Moderately Satisfied 
E) Entirely Satisfied 
 
2. Do you feel that this explanation can be improved? 
A) Disagree 
B) Somewhat Disagree 
C) Neutral 
D) Somewhat Agree 
E) Strongly Agree 
 
3. Would you recommend that patients be provided an explanation in a similar manner? 
A) Disagree 
B) Somewhat Disagree 
C) Neutral 
D) Somewhat Agree 
E) Strongly Agree