Background: Lentigo Maligna (LM), a subtype of melanoma in situ occurring on chronically sun-damaged facial skin, presents unique therapeutic challenges due to its subclinical extension and the need for tissue preservation. Wide Local Excision (WLE) remains the conventional treatment; however, margin control is often difficult. Mohs Micrographic Surgery (MMS), particularly when performed using the spaghetti technique, has emerged as an alternative approach allowing staged peripheral margin assessment while preserving healthy tissue. The economic implications of this technique remain poorly defined.

Objective: To evaluate current evidence on the costs and cost-effectiveness of MMS using the spaghetti technique for facial lentigo maligna.

Methods: A scoping review of PubMed, EMBASE, Scopus, and Cochrane databases was conducted. Studies reporting clinical outcomes, costs, or resource utilization associated with MMS (including the spaghetti technique) for LM were included. Data were synthesized qualitatively with emphasis on economic implications.

Results: Evidence is limited and primarily consists of retrospective studies and case series. MMS with the spaghetti technique demonstrates high rates of complete margin control and low recurrence. Although associated with higher upfront procedural costs compared to WLE, potential economic advantages include reduced need for re-excision, fewer recurrences, and more conservative reconstructions. Formal cost-effectiveness analyses are lacking.

Limitations: The available literature is limited by small sample sizes, lack of standardized economic reporting, and absence of long-term cost-effectiveness models.

Conclusion: MMS using the spaghetti technique appears to offer clinically effective and potentially cost-efficient management for facial lentigo maligna. However, robust economic evaluations are needed to confirm its value and guide clinical decision-making.

Celoria V, Gerbino C, Pertusi G, Gattoni M, Tiberio R (2026) Economic Evaluation of Mohs Micrographic Surgery Using the Spaghetti Tech nique for Facial Lentigo Maligna: Current Evidence and Clinical Implications. JSM Head Face Med 7(1): 1018.

Lentigo Maligna (LM) represents a distinct subtype of melanoma in situ that arises predominantly on chronically sun-exposed skin, particularly in elderly patients. The face is the most commonly affected anatomical site, where the need for oncologic control must be carefully balanced with preservation of cosmetic and functional outcomes [1].

LM is characterized by a high degree of subclinical extension, often extending beyond visible clinical margins. This feature makes complete excision challenging and contributes to relatively high recurrence rates when treated with conventional Wide Local Excision (WLE).

Standard surgical margins (typically 5 mm for melanoma in situ) are frequently insufficient for LM, particularly in the head and neck region [2].

To address these challenges, margin-controlled surgical techniques have been increasingly adopted [3]. Among these, Mohs Micrographic Surgery (MMS) has gained prominence. While traditional MMS relies on frozen section histopathology, its application in melanoma has historically been limited by difficulties in interpreting melanocytic lesions on frozen sections.

To overcome this limitation, staged excision techniques have been developed, including the so-called “spaghetti technique”. This approach involves the removal and histological examination of a narrow peripheral strip of tissue surrounding the lesion, typically processed using paraffin-embedded sections. Once margins are confirmed negative, definitive excision of the central tumor is performed [4].

The spaghetti technique combines the advantages of complete peripheral margin control with improved histopathological accuracy. Clinically, it has been associated with high clearance rates and low recurrence. However, it is also more resource-intensive than conventional excision, requiring multiple procedures, specialized pathology processing, and increased coordination of care [5].

Given rising healthcare costs and increasing emphasis on value-based care, understanding the economic implications of different surgical strategies is essential. While MMS and staged excision techniques may incur higher initial costs, they may reduce long-term expenditures by minimizing recurrence, re-excision, and complex reconstructions.

Despite growing clinical adoption, the economic value of MMS using the spaghetti technique for LM remains poorly defined. This review aims to synthesize current evidence on this topic and identify key gaps in the literature.

This study was designed as a scoping review aimed at providing a comprehensive overview of the available evidence on the clinical and economic outcomes of surgical management of facial lentigo maligna. A scoping approach was selected given the expected heterogeneity of the literature and the limited number of studies specifically addressing cost-related outcomes in this context [6].

A systematic literature search was conducted across PubMed, EMBASE, Scopus, and the Cochrane Library, covering all available records up to January 2026. The search strategy combined both controlled vocabulary and free-text terms related to melanoma and surgical techniques [7]. Keywords included “lentigo maligna”, “melanoma in situ”, “Mohs surgery”, “Mohs micrographic surgery”, “spaghetti technique”, “staged excision”, “cost”, and “cost-effectiveness”. Boolean operators were applied to refine the search, and the reference lists of relevant articles were manually screened to identify additional studies [8].

Studies were considered eligible if they involved patients with lentigo maligna, particularly affecting the face or head and neck region, and evaluated surgical approaches such as Mohs micrographic surgery or staged excision techniques, including the spaghetti technique. Both clinical outcomes—such as recurrence rates and margin status—and economic outcomes, including direct costs, resource utilization, or cost-effectiveness measures, were considered. Original research articles, including observational studies, cohort studies, and economic evaluations, were included.

Studies were excluded if they did not focus on lentigo maligna, investigated non-surgical treatment modalities, or were non-original articles such as reviews, editorials, or case reports. Non-English publications were also excluded [9].

Study selection was performed through an initial screening of titles and abstracts, followed by full-text assessment of potentially relevant articles. Data were extracted using a standardized approach, capturing information on study design, patient population, surgical technique, clinical outcomes, and cost-related measures.

Due to the heterogeneity in study design, outcome reporting, and economic evaluation methods, a quantitative synthesis was not feasible. Therefore, findings were analyzed and presented using a qualitative, narrative synthesis, with particular emphasis on identifying trends in clinical effectiveness and economic implications of different surgical strategies.

The available literature on the economic and clinical outcomes of surgical management of facial lentigo maligna is limited and characterized by considerable heterogeneity in study design, patient populations, and outcome reporting. Most of the included studies consist of retrospective cohort analyses and case series, with only a minority adopting comparative or economically oriented designs. Furthermore, the majority of the evidence focuses on melanoma in situ, particularly lentigo maligna of the head and neck region, reflecting the clinical niche in which margin-controlled techniques are most frequently applied [10].

From a clinical perspective, staged surgical approaches—particularly those based on Mohs micrographic surgery and its variants such as the spaghetti technique—consistently demonstrate high rates of complete margin clearance. This is especially relevant in facial lentigo maligna, where subclinical extension is common and often leads to underestimation of tumor boundaries with conventional excision. Across studies, recurrence rates following margin-controlled techniques are generally low, frequently reported below 5%, and in several series approaching near-zero levels with adequate follow-up [11].

In contrast, conventional Wide Local Excision (WLE), although representing the standard of care, appears to be associated with a higher likelihood of incomplete excision in this anatomical setting. This is largely attributable to the difficulty of achieving adequate margins without compromising cosmetic and functional outcomes. As a result, WLE often necessitates re-excision, which may increase both clinical burden and overall healthcare costs [12,13].

Despite the relative consistency of clinical findings, the economic evidence remains sparse and methodologically inconsistent. Direct cost analyses comparing WLE and margin-controlled techniques are limited, and formal cost-effectiveness studies are notably lacking. Available data suggest that procedures based on staged excision or the spaghetti technique are associated with higher upfront costs, reflecting the need for multiple surgical stages, specialized histopathological processing using paraffin-embedded sections, and increased procedural time [14].

However, several studies indirectly highlight potential economic advantages of these approaches. Improved margin control may reduce the need for additional surgeries, thereby limiting cumulative procedural costs. Furthermore, by enabling more precise excision, tissue sparing techniques may result in smaller surgical defects, often allowing for simpler reconstruction strategies. This may translate into reduced operative time, lower use of advanced reconstructive procedures, and improved cosmetic outcomes, all of which carry both economic and patient-centered implications [15].

Another relevant consideration is the cost associated with recurrence. Recurrent lentigo maligna often requires more extensive surgical management and may be associated with greater morbidity and higher healthcare utilization. By achieving higher rates of initial clearance, margin-controlled techniques such as the spaghetti method may contribute to a reduction in long-term costs, although this hypothesis remains insufficiently validated in formal economic models [16].

Importantly, none of the identified studies incorporated standardized economic endpoints such as Incremental Cost-Effectiveness Ratios (ICERs) or Quality-Adjusted Life Years (QALYs). Similarly, indirect costs, including patient time, productivity loss, and quality-of-life measures, were rarely assessed. This lack of comprehensive economic evaluation limits the ability to draw definitive conclusions regarding the cost-effectiveness of different surgical strategies [17].

Overall, the current body of evidence suggests that while margin-controlled techniques—particularly those based on Mohs micrographic surgery and the spaghetti technique—offer clear clinical advantages in the management of facial lentigo maligna, their economic value remains incompletely defined. The balance between higher initial costs and potential long-term savings represents a key area for future investigation [18].

The management of facial lentigo maligna represents a paradigmatic example of the tension between oncologic radicality and tissue preservation, where surgical precision directly influences both clinical and economic outcomes. This review highlights that margin-controlled techniques—particularly those derived from Mohs micrographic surgery, including the spaghetti technique— consistently achieve superior margin clearance compared with conventional approaches. However, the economic implications of this advantage remain insufficiently defined within the current literature [19,20].

A central finding of this review is the disconnect between robust clinical performance and underdeveloped economic evaluation. While recurrence rates following staged excision and spaghetti-based approaches are consistently low, often markedly inferior to those historically reported for Wide Local Excision (WLE) in the head and neck region, this clinical benefit has not been adequately translated into formal cost-effectiveness frameworks. As a result, current decision-making remains largely guided by clinical intuition rather than quantitative value-based evidence [21].

From a health economics perspective, the interpretation of cost in this setting requires a shift from a procedural to a longitudinal perspective. Although techniques such as the spaghetti method are associated with higher upfront costs—driven by multiple surgical stages, specialized histopathological processing, and increased clinician time—these costs represent only a fraction of the total economic burden of disease [22]. Inadequate initial excision, as may occur with WLE in anatomically complex areas, often leads to re-excision, more extensive reconstruction, and prolonged follow-up, all of which cumulatively increase healthcare expenditure [23].

Importantly, recurrence in lentigo maligna is not merely a clinical inconvenience but a significant economic event [24]. Recurrent disease frequently necessitates wider surgical margins, more complex reconstructive procedures, and additional healthcare encounters. In this context, the high clearance rates achieved by margin-controlled techniques may translate into meaningful downstream cost savings. However, this hypothesis remains largely speculative due to the absence of longitudinal cost analyses and formal modeling studies [25].

Another critical dimension is the impact of surgical strategy on reconstruction and aesthetic outcomes. Facial lentigo maligna often affects cosmetically sensitive areas, where the extent of excision directly influences reconstructive complexity. Tissue-sparing approaches, such as those enabled by staged excision and the spaghetti technique, may reduce defect size and allow for simpler closures. This has implications not only for direct costs— such as operative time and resource utilization—but also for patient-reported outcomes, which are increasingly recognized as essential components of value-based care. Despite this, quality-of-life measures and patient-centered economic outcomes are notably absent from the current literature [26].

The methodological limitations of the available evidence further complicate interpretation. Most studies are retrospective and single-center, with relatively small sample sizes and variable follow-up durations. Economic data, when reported, are often incomplete and lack standardization [27,28]. Key components such as indirect costs, societal perspective, and cost-utility measures (e.g., quality-adjusted life years) are rarely included. Moreover, heterogeneity in healthcare systems and reimbursement models limits the generalizability of cost findings across different settings.

An additional issue is the frequent restriction of evidence to melanoma in situ, particularly lentigo maligna, with minimal data on invasive melanoma. While this reflects appropriate clinical caution, it also underscores the narrow scope of current economic evaluations. As the indications for margin-controlled techniques evolve, there will be a need to expand economic analyses to broader patient populations.

Taken together, these findings suggest that the current evidence base is insufficient to definitively establish the cost-effectiveness of margin-controlled surgical techniques in facial lentigo maligna. Nevertheless, the consistent demonstration of superior margin control and low recurrence rates strongly supports their clinical value. The challenge for future research lies in integrating these clinical benefits into robust economic frameworks that capture both short-term costs and long-term outcomes [29].

Future studies should prioritize prospective, comparative designs incorporating standardized cost reporting and long-term follow-up. The inclusion of cost-utility analyses, particularly those incorporating quality-adjusted life years, will be essential to inform healthcare policy and clinical guidelines. Additionally, the integration of patient-reported outcomes will provide a more comprehensive assessment of value, particularly in anatomically sensitive regions such as the face.

In the era of value-based medicine, surgical decision making must extend beyond technical success to encompass economic sustainability and patient-centered outcomes. Margin-controlled approaches derived from Mohs micrographic surgery, including the spaghetti technique, are well positioned within this paradigm. However, their widespread adoption will ultimately depend on the generation of high-quality evidence demonstrating not only clinical superiority but also economic value [30].

The management of facial lentigo maligna remains a complex clinical scenario in which oncologic control, cosmetic preservation, and healthcare resource utilization must be carefully balanced. This review highlights that margin-controlled surgical approaches, particularly those derived from Mohs micrographic surgery and implemented through staged techniques such as the spaghetti method, offer clear clinical advantages in terms of margin assessment and local disease control.

Despite these strengths, the current evidence base remains insufficient to support definitive conclusions regarding cost-effectiveness. The available literature is limited by methodological heterogeneity, a predominance of retrospective designs, and the absence of standardized economic endpoints. In particular, the lack of robust cost utility analyses incorporating Quality-Adjusted Life Years (QALYs) represents a critical gap, especially in a condition where long-term outcomes and recurrence play a central role in determining value [31].

Importantly, this review underscores the need to move beyond a narrow focus on upfront procedural costs toward a more comprehensive, longitudinal evaluation of economic impact. While staged excision techniques may incur higher initial costs, their potential to reduce recurrence rates, minimize the need for re-excision, and enable tissue-sparing reconstruction suggests that they may be economically advantageous over the full course of disease management. However, this hypothesis remains largely untested in high-quality prospective studies.

Another key finding is the absence of patient-centered economic outcomes in the existing literature. Given the predominance of facial involvement in lentigo maligna, surgical decisions have significant implications for quality of life, aesthetic outcomes, and psychosocial well-being. Future economic evaluations should therefore incorporate patient-reported outcome measures alongside traditional cost metrics to provide a more holistic assessment of value.

From a clinical perspective, the evidence supports the use of margin-controlled techniques, including the spaghetti method, in selected cases of facial lentigo maligna, particularly where subclinical extension is suspected or tissue preservation is critical. However, their broader adoption will depend on the generation of high-quality evidence demonstrating not only clinical efficacy but also economic sustainability across different healthcare systems [32].

Future research priorities should include prospective comparative studies between wide local excision and staged excision techniques, standardized reporting of direct and indirect costs, and the integration of long-term follow-up data. Additionally, the development of decision analytic models incorporating recurrence, reconstruction complexity, and patient-reported outcomes will be essential to guide evidence-based clinical and policy decisions.

In conclusion, while margin-controlled surgical approaches such as Mohs micrographic surgery using the spaghetti technique represent a promising strategy for the management of facial lentigo maligna, their cost effectiveness remains incompletely defined. Advancing the field will require a concerted effort to generate rigorous, standardized, and patient-centered economic evidence capable of informing modern value-based care.

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