Viewpoints
An Interview with Carl Vinciullo
By Arif Aslam, MBChB, FRACP, FACD
The following is provided by Carl Vinciullo, recently retired adjunct Clin A/Prof at the University of Western Australia (WA) and former director of Mohs surgery at Oxford Dermatology, Perth, WA. He is a medical graduate from the University of WA and fellow of the Australasian College of Dermatologists. Between 1986-1988 he completed a Mohs surgery fellowship with Dr. Perry Robbins who was then the Head of Mohs Surgery in the Department of Dermatology at NYU Medical Center.
More than 21 dermatologists from Australia, New Zealand, and the UK have completed a yearlong fellowship training program in Mohs surgery under his direction. He has been actively involved in research for more than 30 years and has widely contributed to the worldwide literature on dermatological surgery.
1. What sparked your interest in Mohs surgery?
My original career path as a junior medical officer in the early 1980s was to train in surgery. I undertook house residencies in general, plastic/reconstructive and cardiothoracic surgery. I was mentored by excellent senior registrars and consultants and given considerable opportunity for hands on surgery including opening chests for open heart surgery and doing skin grafts.
I was strongly encouraged to undertake surgical training. Dermatology came into view by pure serendipity when a close friend and colleague told me he was applying for a dermatology residency. I was intrigued. The closer I looked, the more attractive this specialty seemed, especially as there appeared to be a nascent surgical element to the specialty. I was fortunate to be selected for dermatology training along with my friend in 1983.
Dermatologic surgery was in its early stages in 1983, but I was quick to see the opportunities to apply my surgical skills and knowledge. In the early years of training, I was instructed to do curettage for skin cancers even on the nose and face. From my plastic surgery experience, I knew it would be better to excise many of these lesions and even to undertake flaps and grafts. My dermatology consultants were in equal measure surprised and intrigued by my surgical suggestions and to their credit allowed me a free hand.
In time, Chemosurgery/Mohs surgery came to my attention mainly through reading the Journal of Mohs Surgery and Cutaneous Oncology, and subsequently I was lucky enough to train with Dr. Perry Robins in New York.
2. Give us a summary of your clinical practice
My private dermatology practice started in 1988 and was by necessity a combination of both general dermatology and Mohs surgery. There was little support for Mohs surgery other than from a few enlightened dermatologists. Surgical specialists and most family physicians had no knowledge about the technique, and the prevailing view was that dermatologists were not trained to undertake surgery of any sort, let alone Mohs surgery.
Having found time during my Mohs Fellowship to visit Dr. Roy Geronemus, Dr. Jay Barnett, Dr. Saul Asken and Dr. Walter Unger in New York, and Dr. Thomas Alt in Minnesota, amongst others, I was also able to offer cosmetic surgery procedures such as Candela laser for port wine stains, CO2 laser, hair transplantation, silicone fillers, dermabrasion and liposuction.
My practice at Royal Perth Hospital involved general dermatology along with sessions dedicated to training dermatology registrars in surgery and providing the first adult and paediatric laser service for port wine stains.
In addition, I set up visiting clinics to remote and rural areas of Western Australia starved of general dermatology services.
3. What did you enjoy most about your practice?
Without a doubt, the wide scope and variety of my practice was the greatest attraction for me along with a passion for dermatopathology. It took years if not a decade to establish a solid base of Mohs surgery. In the meantime, I was increasingly busy with cosmetic and laser surgery as well.
Until the last 5 years before my retirement, I also retained a great interest in the management of general dermatology patients with over 50 patients under my care on biologics for severe psoriasis, along with treating the full gamut of autoimmune and other medical diseases fed mostly from my remote and rural visiting practices.
4. What did you enjoy least about your practice?
As with many of us, balancing life and work commitments was very difficult. Long hours at the office are not conducive to balance and were a constant challenge.
Managing the human resources and financial sides of practice was equally problematic and could not have been managed successfully if not for the input from my trusted advisors.
5. Clinically, what did you find most challenging in your career?
Managing advanced tumour-Mohs cases is the most challenging aspect. Having to undertake mutilating surgery in the patient’s best interest is sometimes necessary, but always difficult and almost unbearable on the rare occasion the tumour cannot be cleared. Having to call on surgical colleagues to assist in tumour clearance is particularly problematic, especially if not anticipated prior to commencement of Mohs surgery. Where complex and unanticipated major reconstruction is required provides both challenges and potentially great rewards when successful. Managing failed or poor repair outcomes is equally a challenge.
6. How have the utilisation and case numbers of Mohs surgery changed throughout your career in Australia?
Mohs surgery was first introduced to Australia in the late 1970s at the Skin and Cancer Foundation in Sydney. Dr. Perry Robins was invited to Australia in 1978 to train a few dermatologists in Sydney, but there were no formal Fellowship-trained surgeons until Dr. Robert Paver from Sydney trained with Sam Stegman and Ted Tromovitch in San Francisco, and I trained with Perry Robins in New York, both in 1986/1987.
It is true to say, however, that in the late 1980s Mohs surgery was not well received in Australia. It was not until 1991 that Dr. Robert Paver and the Skin and Cancer Foundation were able to convince government through Medicare Australia that “microscopically controlled serial excision” was both clinically advantageous and cost effective that coding and Medicare reimbursement was established.
Only then did Mohs surgery start to gain respectability and acceptance. The number of cases performed by about 10 Mohs surgeons started from a low base in the early 1990s to more than 12,000 cases per annum performed by some 50 Mohs surgeons in the 2010s. This upward trend has continued into the 2020s. By the end of my career in 2021, there existed strong interdisciplinary cooperation with ophthalmology/oculoplastic surgery, ENT/Head and neck surgery and to a lesser but not insignificant amount with plastic and reconstructive surgery.
7. What challenges do you foresee the Mohs college and in particular Australian Mohs surgeons facing in the future?
The greatest ongoing challenge in my view remains the acceptance of Mohs surgery by our medical and surgical colleagues. We know through extensive published research that Mohs surgery is the gold standard of care and a highly cost-effective treatment for high-risk keratinocyte and other non-melanoma skin cancers, however this is still not uniformly acknowledged in Australia.
The recent trend toward the use of Mohs surgery for melanoma in situ and invasive melanoma is in my personal view a risk to the ongoing acceptance of Mohs surgery. By nature of the metastatic risk of melanoma and the whole debate about sentinel lymph node biopsy with the potential for early targeted immunotherapy we run the risk of “throwing out the baby with the bath water” in taking on melanoma, whatever the purported benefits of the technique for this malignancy. My very supportive and highly trusted dermatopathology colleagues are also strongly of this view and have been influential in my thinking.
8. What advice would you give fellows just starting practice?
In Australia, we now have a trend toward more dermatology graduates than not wanting to take on Mohs surgery training. I cannot imagine there are enough cases to go around risking the scenario of low level /low-risk cases being treated this way. This will dilute the experience of managing high-risk cases and perhaps under-skill those who have trained in some programs.
My advice to prospective Fellows would be to choose programs that are not only fully accredited but those that can demonstrate they perform a significant number of genuinely complex cases and that are very strong in their reconstructive component. Beyond that, to remain highly ethical in practice with regard to choosing cases that adhere closely to the high-risk categories.
9. What are you enjoying most in retirement?
The greatest joy is to have time to do the mundane; walking the dog twice a day, cycling long distances into the Perth Hills, cooking delicious meals for the family rather than depending as I have for 40 years on the good graces of my long-suffering wife, keeping the home garden in pristine condition, visiting my amazing 96-year-old mother now in aged care, loading up the Ram pick-up with a camper trailer and exploring Australia…….all with little to no stress or pressure.
10. What would people be surprised to know about you?
Firstly, that I had some early aspirations to climb high mountains starting with my summiting of Mount Taranaki (Mt. Egmont, 2518m) in New Zealand as a medical student in 1978. Climbing extensively in the French Alps followed, including a failed attempt to summit Mont Blanc (4808m). In the Himalayas, Kala Pattar (5545m) and Everest base camp (5364m) followed in the 2000s before I realized that the risks of going higher were definitely not worth it!
Another surprise might be that I have for nearly 24 years been a part-time farmer looking after 100 acres of rolling hills in the south west of West Australia; raising cattle and sheep, looking after bees that produce the most wonderful Jarrah honey, tending to a flock of chickens, growing olives to make the most amazing extra virgin olive oil and table olives, and making sure we have at all times farm grown fruit, nuts, raspberries and blueberries. This labour of love has since my retirement in December 2021 become an abiding near full-time passion.