Mohs Micrographic Surgery

Mohs Surgery

Mohs Skin Cancer Surgery
Superior Training, Superior Results

WHAT IS MOHS SURGERY?

Mohs micrographic surgery is a well-established outpatient method of treating skin cancer which provides the highest cure rate – approximately 98% for basal cell and squamous cell carcinomas. The procedure was developed by Dr. Frederick Mohs at the University of Wisconsin in the 1930’s and is now used throughout the world.

Skin cancers can be like an iceberg – there is more below the surface of the skin than can be seen on top. Mohs surgery is unique because it allows the surgeon to precisely remove skin cancers while preserving the maximal amount of normal skin. During surgery, the surgeon will cut around and underneath the cancer and then examine every edge under the microscope to ensure it has all been removed. If more cancer is seen at the edge, the surgeon will remove more skin but only in the area with remaining cancer. In this fashion, the surgeon removes all of the cancer while preserving the normal surrounding skin. The entire procedure is done safely under local anesthesia in the office, avoiding the need for general anesthesia.

For more information about Mohs micrographic surgery visit www.mohscollege.org

OUR DOCTORS ARE ACMS MEMBERS

All our dermatologic surgeons are Fellowship Trained Mohs Micrographic surgeons. To become an American College of Mohs Surgery Fellow, physicians who have finished their residency complete an additional 1-2 years of hands-on training program. ACMS trainees receive a comprehensive education which includes skin cancer removal using the Mohs procedure, pathology, and reconstructive surgery for optimal function and aesthetic outcomes. Additionally, they complete a minimum requirement of 500 Mohs cases under expert supervision. Cases include common skin cancers (basal and squamous cell carcinomas) as well as rare cancers. Fellowship Trained Mohs surgeons have extensive experience removing cancers from difficult locations and complex wound reconstructions. When it comes to your health, don’t settle for less than the best. Have an ACMS Fellowship Trained Mohs Micrographic Surgeon remove your skin cancer.

FREQUENTLY ASKED QUESTIONS

What medications can I take?

The following medications increase your risk of bleeding during and after the surgery and should be stopped for 2 weeks prior to the procedure and for 2 days following the surgery:

Ibuprofen (Advil)
Fish oil
Vitamin E
Ginko
Garlic
Ginseng
Ephedra (Ma Huang)

Otherwise, take any medication that you would normally take. Bring any medication with you that you would normally take during the day.

What about aspirin, Plavix, Coumadin (warfarin), and Eliquis?

If you are taking these medications, which thin the blood, because you have had a stroke, heart attack, blood clot, artificial heart valve or have atrial fibrillation, then you should continue taking them for the surgery. This is likely to increase minor bleeding during the surgery which can be controlled, but is much less dangerous having another stroke, heart attack, or blood clot.

If you are taking them just as a preventive health measure, but have NOT had a stroke, heart attack, blood clot, or artificial valve, then please check with your primary care doctor or internist to see if it is safe to stop them for surgery. Do NOT stop them without checking first. Aspirin (including baby aspirin) should be stopped 10 days prior to surgery.

If you take Coumadin, please have a routine coagulation study (PT/INR) drawn within 1 week of your surgery day. Have the results faxed to Vivida Dermatology (702) 933-1444.

What about alcohol and cigarettes?

We ask that you have no alcohol beginning 2 days before surgery until 2 days after surgery. Alcohol thins your blood and can lead to bleeding problems during you surgery.

Stop smoking 1 week before surgery and for 2 weeks following surgery. Smoking greatly impairs your body’s ability to heal and may cause you to have unsightly scarring.

Can I take something to relax me?

Yes. We have Valium (diazepam) in the office. Once your doctor has reviewed your history and medications, they can discuss with you if you think that would be helpful for you during the procedure. Keep in mind that if you take a Valium, you cannot drive yourself home – you will need someone to drive you. Arrange this beforehand if you think you may need something to relax you on the day of surgery.

What should I wear on my surgery day?

Wear loose, comfortable clothing. Also, avoid wearing white colors please.

The biopsy area appears to have healed. Do I still need to have the surgery?

Skin cancer has “roots” under the skin which are not seen with the naked eye. The biopsy which was done was just intended to sample the tumor, and not completely remove it. Even though the surface of the skin has healed, there is still cancer below the surface which will regrow if not treated.

The pathology states that the “margins are clear.” Do I still need to have the surgery?

Again, the biopsy which was done was just intended to sample the tumor, and not completely remove it. The pathologist is looking at the biopsy samples is only seeing 1% or less of the margin. Even though the surface which the pathologist examined appears “clear,” it is very common to find that there is still cancer below the surface which will regrow if not treated.

Will my cancer become a melanoma?

No. Basal cell carcinoma, squamous cell carcinoma, and melanoma are all unique, different types of cancer. They cannot change types. A basal cell or squamous cell cancer will never become a melanoma.

What will happen if I just leave the area and do nothing?

In rare cases, the biopsy may have cured the cancer. However, the great majority of tumors are not removed by the biopsy and will continue to grow. Basal cell carcinoma does not spread through the body, but simply grows and eats away the skin in that area. While very rarely fatal, they can be very problematic if left untreated due to bleeding, infection, and distortion of normal appearance. Squamous cell on the other hand does have a risk of spreading to other body parts (metastasizing), and the longer treatment is delayed the greater the risk of spread.

What are the chances I will get another cancer?

About 40% over the next 5 years. Meaning 4 out of 10 people who have had a skin cancer will get another one with 5 years. We recommend regular skin checks with a dermatologist every 6 months for patients who have a history of skin cancer. In some case, we may even recommend more frequent visits. The goal of regular visits and skin exams to perform preventive maintenance as able and catch any new skin cancers as early as possible when they are small and easy to treat.

I have a wedding, family photo or other special event in 2 weeks. Should I still have the surgery?

In most cases, delaying treatment 2-3 weeks is not dangerous or problematic. We understand that bandages, bruising, or a fresh scar may ruin a photograph or special event.

Will there be much pain during or after the surgery?

We use local anesthesia to control the pain during surgery and keep you comfortable. Normally patients experience only mild pain after surgery, which is usually controlled by Tylenol or Advil. In some rare cases, our providers will prescribe a stronger pain medication.

How should I take care of the wound after surgery?

Our staff will demonstrate how to care for your wound and will give you written instructions. You will also have an after-hours number for emergencies. Usually you will return to have your sutures removed in 1-2 weeks.

When can I resume normal activities after surgery?

We recommend that you avoid strenuous activities for 1-2 weeks after your surgery. This includes exercise, golf, yard work, and any heavy lifting. Be aware that you may have significant swelling, redness, or bruising for one or two weeks, especially if your cancer is on the central face (forehead, eyes, nose, and lips).

What are the alternatives to surgery?

There are various other methods of treating skin cancer. The decision to use Mohs surgery takes into account several factors including the type of cancer, the location, and prior treatments attempted.

Other methods used for treating skin cancer include:

Scraping and Burning (Electrodessication and Curettage): This technique is used at times on the trunk, arms, and legs for early, shallow skin cancers. The recurrence rate is higher and the wounds can take weeks to months to heal completely. In addition, there is no microscope confirmation that the tumor has been completely removed. If the tumor regrows it is mixed in with scar tissue which makes it more difficult to treat.
Simple Excision: This is where the doctor cuts out the skin cancer with a safety margin of normal skin (usually 4-5 mm = ¼ inch), stitches you back up, and sends the specimen to a lab for examination of a portion of the margin. You then wait 1-2 weeks for the results. This technique has a higher recurrence rate because the pathologist is only examining a portion of the margin and often removes more normal skin. This fine when we have skin to spare, but on the face or other areas where skin may be tight, we try to take as little skin as possible.
Anti-Cancer Creams (Efudex, Carac, Imiquimod): While we know it sounds appealing to use a cream instead of surgery, there are several drawbacks with the cream: (1) they are really only effective for early, shallow cancers as the creams cannot penetrate very deep in to the skin; (2) they must be used for several months to work and cause a lot of irritation and often breakdown of the skin; (3) even if used properly, the cure rate is only 65-70%.

How long will my surgery day last?

The length of Mohs surgery is unpredictable because some skin cancers grow underneath the skin more than at the surface. There are multiple brief episodes of surgery followed by long periods of waiting while the tissue is processed and evaluated under the microscope. Usually the day lasts 3-5 hours, but occasionally can last all day. You may want to bring reading material, food for lunch or snacks, or a friend/loved one to help you pass the time.

Is there anything else I should do to prepare for my surgery?

Eat breakfast on the day of surgery and bring a lunch.

Arrange for someone to drive you home from surgery in case your postoperative bandage covers your eyes or if sedative medications are required

The thought of undergoing surgery for skin cancer produces anxiety in many patients. One of the main goals of Vivida Dermatology is to provide the best care and maximum comfort to our patients. We do that by educating our clients about the entire procedure and our vast experience in the same type of skin cancer surgery, so that the patient understands fully that they are in good hands. In order to help you understand the process of Mohs surgery and prepare for your day, please read the information below. In addition, you can visit our testimonials page to read about the experiences of other patients.

YOUR MOHS SURGERY DAY

Please arrive 15 minutes early to your appointment time to check in (or 30 minutes if it is your first time visiting the office in order to complete paperwork).

Be prepared to spend the entire day with us – we cannot predict how long the surgery will take. Most patients are here 3-6 hours, but there are times that the removal and reconstruction can take longer.

Once you arrive and finish your paperwork:

The front desk staff will register you and verify your insurance information

A member of the nursing staff will then escort you to a procedure room and review your medical history, medications, allergies, and referring physician

You will then be asked to review and sign a consent form giving us permission to perform the surgery

The nurse will then cleanse the skin and take a photograph of your skin cancer site. This is done so that we can have a detailed record and send a letter to your referring physician.

You will then meet your doctor who will explain the procedure, confirm the correct site with you, and answer any questions you may have.

The skin will then be numbed with local anesthetic (lidocaine). There is often a burning and stinging as the medicine is injected and begins to take effect. We know that this can be most uncomfortable part of the procedure and aim to make this as painless as possible.

After the skin is numb, your doctor will then begin the surgery. The first step in Mohs surgery is to try to determine the extent of the tumor under the skin. This is done with specialized skin tool called a curette, or with the scalpel.

Once the extent of the tumor has been estimated, the doctor will remove all the visible tumor along with a very small margin of skin.

The nurse will then stop any bleeding using cautery and bandage will be placed.

You will then be shown to the waiting. There is coffee, water, juice, and snacks available. In addition, we have free wireless internet as well as television.

The doctor will then take the removed skin (tissue) to the lab. The specimen is carefully oriented, marked with colored dye and then processed and prepared to be looked at under the microscope by your doctor. This process takes approximately 90 minutes in most cases.

Once the tissue is ready, your doctor will examine it under the microscope to see if there is any cancer remaining.

1. If the doctor finds that there is still cancer left, they will mark the area on a special map which corresponds to your skin. You be called back to the procedure room, where the nurse will remove the bandage and place more anesthetic in the skin. The doctor will then carefully remove additional skin only from the area(s) where the cancer is still present. This process will be repeated as many times as necessary to completely remove the cancer. About half of people require more than one pass.

1. If all of the cancer has been removed, the nurse will begin preparing you for the repair as explained below.

Once the cancer is completely removed, the nurse will take another photograph and your doctor will decide how to best repair/replace the skin which was removed by the cancer.

We will ask you if you would like to look at the wound. We recommend and encourage you to look so that you can better understand the extent of the tumor and what will be necessary to repair the wound. However, you are not required to look if you don’t want to.

Wound Closure (Repair)

When all of the cancer has been removed, your doctor will discuss all the options for repairing your wound, which is most often performed the same day, but in rare circumstances may be postponed to a later date. Options for wound repair include:

· Doing nothing. Simply allowing the wound to heal by itself. The skin has a remarkable ability to regenerate and heal. While it may take longer, 4-8 weeks, it can lead to excellent results. This may also be the only option in certain areas where there is very limited skin like the shins.

· Simple Side-To-Side Repair (also called primary closure or linear repair). This is where the skin is stitched back together side-to-side in straight line. This is the most common type of repair.

· Skin Flap: this is where skin adjacent to the wound is moved over to cover the wound

· Skin Graft: a graft is when a piece of skin is harvested from another site (often behind the ear) and placed to cover the wound like a patch.

· In rare circumstances, the location or size of wound may require referral to plastic surgeon or eye surgeon for repair. Your doctor will let you know if they anticipate this being the case so that arrangements can be made in advance.

Following Surgery

Most people experience mild pain following surgery. The pain tends to peak around 8 hours after surgery and is generally gone within 24 hours. Ibuprofen and Tylenol work well to alleviate this pain and will be reviewed on your post-operative instruction sheet.

If sutures (stitches) were used to close your wound, you will need to be seen to have them removed. Stitches on the face or neck are generally removed in 5-7 days. Stitches on the trunk, legs, and arms are generally removed in 10-14 days. Please do not schedule surgery near a vacation or time when you will not be available for us to see you for follow-up.

Once your wound has healed or the sutures have been removed, the scar will continue to mature and improve in appearance for 6-12 months. You should begin to massage the scar 1 month after surgery to help the scar soften and fade more quickly.

Numbness in the surgical area is not uncommon and can take up to 18 months to normalize. During this time, sensations of itchiness, tingling, and occasional sharp or shooting pains can occur. These sensations are normal and will subside as the nerves in the area heal completely.

The thought of undergoing surgery for skin cancer produces anxiety in many patients. One of the main goals of Vivida Dermatology is to provide the best care and maximum comfort to our patients. We do this by educating our patients about the entire procedure and reassuring them of our vast experience in skin cancer surgery. In order to help you understand the process of Mohs surgery and prepare for your day, please read the information below.