Abstract
<jats:p>Background: Cases requiring 13 or more tissue sections in Mohs micrographic surgery (MMS) demand extended operative time, additional resources, and often specialised closure techniques. Pre-operative identification of such cases would improve surgical scheduling, resource allocation, and patient counselling. We aimed to develop and validate a machine learning prediction tool using pre-operative clinical features to identify cases likely to require13 sections. Objectives: To develop and validate machine learning models for predicting which Mohs procedures will require 13 sections, using pre-operative clinical features, and to identify key predictive factors. Methods: We analysed 408 consecutive Mohs procedures with 16 pre-operative clinical variables. Thirty machine learning algorithms were evaluated, including ensemble methods (Stacking, Voting), gradient boosting (XGBoost, LightGBM, CatBoost), neural networks (3-7 layers), support vector machines, and traditional classifiers. Model performance was assessed using 5-fold stratified cross-validation and independent test set evaluation. Feature importance was determined using SHAP (SHapley Additive exPlanations) analysis. Results: The stacking ensemble achieved the highest cross-validation AUC of 0.891 (95% CI: 0.849-0.934) and test AUC of 0.884. Tumour area (cm2), calculated using the ellipse formula to approximate clinical tumour morphology, emerged as the strongest predictor (SHAP importance: 0.141), followed by tumour size dimensions (0.086 and 0.068), aggressive histopathology (0.046), and recurrence status (0.035). Wide neural network architectures (5-layer) outperformed deeper configurations (7-layer). The model demonstrated 70.7% high-confidence predictions with uncertainty <15%. Conclusions: Machine learning models using pre-operative clinical features can accurately predict which Mohs procedures will require 13 or more sections. The stacking ensemble approach provides robust predictions suitable for clinical decision support. External validation in multi-centre cohorts with diverse patient populations and practice patterns is warranted to assess model generalisability.</jats:p>