Mohs Microscopic Surgery

A Skin Cancer Diagnosis

A diagnosis of cancer is a frightening experience for most. Hearing this diagnosis, questions like “Is this terminal?” “How did this happen?” and “What can be done?” immediately come to mind. Having solid information about treatment options helps alleviate fears and lays the groundwork for possible next steps.

Background

Skin cancer is the most common form of cancer, with more than 3.5 million new cases diagnosed every year, according to the American Cancer Society. Fortunately, the most common types of skin cancer, basal cell and squamous cell, also are the most curable forms of all cancer. Mohs micrographic surgery is a preferred treatment choice for these types of skin cancers.

However, if left untreated or not completely treated, skin cancer can continue to progress, involving adjacent parts of the body and can spread, or metastasize, to distant parts of the body. Fortunately, this is by far the exception rather than the rule with basal skin cancer, and to a lesser degree, squamous cell skin cancer.

Melanoma, which accounts for 73,000 cases of the 3.5 million skin cancer cases annually (American Cancer Society), is a different and more dangerous kind of skin cancer and is not typically treated with Mohs surgery.

Exposure to Sunlight

Excessive exposure to the sun is the single most important cause of all forms of skin cancer. Even sun exposure that occurred during childhood can result in skin cancer much later in life. Fair-skinned people who tan poorly are most susceptible to sun damage and develop skin cancers at a higher rate.

Treatment Options

There are several effective types of treatment for skin cancer, including cryrotherapy or freezing; electrodessication and curettage (scraping and burning); simple excision; and Mohs micrographic surgery. Selecting the best treatment for each patient is an important step. Factors to be considered are the cancers size and location, whether the cancer has been treated

previously, and the age and health of the patient. You have been referred for Mohs treatment for your type of skin cancer.

It’s important to remember when treating skin cancer that these types of cancers often have “roots” that extend far beyond what you or your physician may be able to see with the naked eye. If not completely removed, skin cancers can continue to grow, and can invade and destroy surrounding parts of the body.

What is Mohs Surgery?

Mohs micrographic surgery is an advanced treatment that offers the highest potential cure for most skin cancers, while minimizing the cosmetic effects of the treatment. This highly specialized and effective outpatient procedure is named after its inventor, Dr. Frederick E. Mohs.

With Mohs surgery, the cure rate is 97 percent to 99 percent, even if other treatments have failed. Mohs surgery also offers the highest cure rate while preserving the largest amount of surrounding normal tissue, an important factor for minimizing scarring, especially when dealing with facial cancers.

The Surgical Process

The use of special microscopic techniques employed by
a highly trained team are the keys to the treatment’s success rate. Mohs uses an orderly process conducted in stages. After the clinically visible extent of the tumor is determined, a thin section of tissue is removed. This tissue is processed and turned into a microscopic slide. The physician examines the slide, looking for any roots of the disease that may exist under the skins surface. If any cancer roots are identified past the area removed, a second stage is conducted in the identified area, thereby preserving as much healthy normal tissue as possible throughout the procedure. This process is repeated until no tumor is found.

Most tumors are removed in one to three surgical stages, ensuring the highest cure rate for the skin cancer while removing as little healthy skin as possible.

le excision; and Mohs micrographic surgery. Selecting the best treatment for each patient is an important step. Factors to be considered are the cancers size and location, whether the cancer has been treated

previously, and the age and health of the patient. You have been referred for Mohs treatment for your type of skin cancer.

It’s important to remember when treating skin cancer that these types of cancers often have “roots” that extend far beyond what you or your physician may be able to see with the naked eye. If not completely removed, skin cancers can continue to grow, and can invade and destroy surrounding parts of the body.

When is Mohs surgery used?
Mohs surgery is reserved for cases where a simpler, more rapid treatment would be less effective. Mohs is recommended for the following:

  • Skins cancers of the head and neck where the preservation of healthy skin is important.
  • When a skin cancer returns after a prior treatment.
  • When the cancer is large.
  • When the cancer is considered more aggressive on the initial biopsy.The goals of Mohs surgery are complete removal of all detectable cancer cells and reconstruction of the surgical wound with the optimal cosmetic result.

When is Mohs surgery used?

Mohs surgery is reserved for cases where a simpler, more rapid treatment would be less effective. Mohs is recommended for the following:

  •   Skins cancers of the head and neck where the preservation of healthy skin is important.
  •   When a skin cancer returns after a prior treatment.
  •   When the cancer is large.
  •   When the cancer is considered more aggressive on the initial biopsy.The goals of Mohs surgery are complete removal of all detectable cancer cells and reconstruction of the surgical wound with the optimal cosmetic result.

Preparing for Mohs Surgery

No special preparations are required before surgery. Below are some guidelines:

  • Be well rested and eat a good breakfast.
  • Take your usual medications unless otherwise directed by your physician.
  • Tylenol may be used in place of aspirin or ibuprofen for pain.
  • Avoid alcoholic beverages and smoking for several days before and after your surgery to aid in healing.
  • If you’ve been advised to take antibiotics before surgical or dental procedures, please contact our of ce and discuss this with the staff. Your physician may place you on antibiotics post operatively in some cases.
  • Wash your hair the night before or the morning of surgery because your wound dressing may have to remain dry for 24 hours or longer after surgery.
  • The length of time of your Mohs surgery can vary, depending on the size and location of the tumor, and the type of reconstruction required. The average time for surgery is between two hours and four hours, but you should plan on spending the majority of the day at our of ce.
  • Please limit the number of family members or friends accompanying you on the day of surgery, as our waiting space is limited.
  • You will spend time waiting for the tissue to be processed in the lab during each surgical stage, so feel free to bring reading materials or other handiwork with you.

Day of Surgery

We schedule surgical appointments throughout the day. Here are some general guidelines for the day of surgery:

  • Be sure to eat breakfast and lunch as usual, unless otherwise directed by your physician.
  • Wear loose tting clothing and avoid pullover tops or shirts.  If your cancer is on your face, please do not wear makeup on or around the affected area.

Your written consent will be obtained, and photos are often taken to record the site. We will clean the operative site with antibacterial soap, and we may outline the visible tumor. We will numb the surgical area with a local injection similar to what you received for your biopsy; this avoids the potential risks associated with general anesthesia. Surgically removing the rst stage will take several minutes, and electric cautery may be used to stop bleeding.

Depending on the amount of tissue removed, it will take between 20 and 60 minutes to process each stage of the tissue in the lab. During this time a temporary bandage may be placed on the surgical site, and you may be moved to a surgical waiting area while the tissue is processed, stained and examined by the physician.

If any cancer roots are identi ed extending beyond the original surgical site, more tissue will be removed and processed. We will repeat this step-by-step process, usually complete in between one and three stages, until there is no more detectable cancer.

Reconstruction

Because Mohs surgery removes as little healthy tissue as possible, scarring is minimized. We can discuss reconstruction options during the pre-operative visit, but the best options cannot be determined until the final post-Mohs surgical wound is established the day of the surgery.

After your skin cancer has been surgically removed, the physician will decide how best to care for the wound, depending on its size and location, to minimize scarring. Occasionally, the best option is to allow the open wound to heal by itself.

Most wound closures are performed the day of surgery in our of ce. Mohs surgeons are trained in many forms of specialized stitched wound closures, including skin aps and graphs. However, other surgical specialists may be consulted for unique closures if necessary.

When another physician performs reconstruction, we may be able to coordinate this to occur on the same day or on a subsequent day. There is no harm, and often a bene t, to delaying reconstruction for several days.

If reconstruction is extensive, it may require hospitalization. This is the exception, however, as most wounds are repaired immediately in our of ce while the site is still numb.

What to expect after Mohs surgery

Your surgical wound will require care after surgery, and post-surgical instructions will depend on the type of closure you received. Occasionally, preventative antibiotics may be prescribed after surgery. Plan on taking it easy for at least a week after surgery. Stitches are removed 7 to 21 days after surgery, depending on the type of reconstruction and the location. You will receive an after-hours phone number to call if any problems arise.

Most patients report minimal pain that responds readily to Tylenol after surgery. The site will be similar to a bruise in that it is tender to touch but does not hurt much if untouched. If you have signi cant pain, please call your physician.

Skin cancers frequently involve sensory nerves, and months
may pass before the sensation around your surgical site returns. Itching around the site is common, and the area may feel tight for a period of time after surgery. Complete healing of the surgical site can take as long as one year or longer; the scar will be most noticeable in the rst weeks or moths after the surgery. Please know the surgical scar can be revised after enough healing has occurred. For the rst few weeks, the site may feel swollen or lumpy. Redness can also persist for a long time, particularly in fair-skinned patients.

We will assess your healing after the procedure in subsequent appointments. Studies show that once you develop skin cancer, there is a strong possibility you may develop other skin cancers. Plan on regular follow-up skin exams and be sure to report any new growing, bleeding or non-healing areas to your physician.

Risks after Mohs surgery

Because Mohs surgery is performed on an outpatient basis, the risks are minimal, compared with all other types of surgery.
Your physician may cover with you risks associated with your particular case; it is impossible to discuss all possible risks as each case is unique. However, the following are risks that are the exception, not the rule, with Mohs surgery:

  • The defect created by removing the cancer may be larger than anticipated. There is no way to predict the exact
    size of the defect before surgery, and this is why the final decisions about reconstruction are not made until the final defect is determined the day of the surgery.
  • There is always a scar when you perform surgery. Your physician’s goals, once all traces of the cancer are removed, are to obtain optimal cosmetic results with complete removal of the entire tumor. Again, one of the primary benefits of Mohs surgery is to leave with the smallest wound while achieving the highest cure rate.
  • Despite our best efforts, the wound may heal poorly. Bleeding, poor health, smoking and diabetes among other conditions, can impact healing. Occasionally flaps and graphs used for reconstruction fail. However, despite these challenges, a good cosmetic result is still possible, and scars can be revised at a later date.
  • There may be permanent loss of sensation, or more rarely, a loss of local muscle function. Occasionally, the cancer will invade nearby nerves. In these cases, the nerves must be removed in order to remove the cancer. There are certain areas where this rare problem can occur more frequently, and your physician will discuss with you before surgery.
  • Tumors can occur in areas that are cosmetically sensitive (eyelid, nose, lips) requiring the removal of portions of those areas. Although a good cosmetic result is more dif cult in these situations, there are many reconstructive procedures that can be performed to optimize appearance.
  • Anytime you cut the skin (even when shaving), infection can occur. However, this is very rare (less than one percent) in dermatologic surgical treatments like Mohs.
  • Postoperative bleeding can occur due to many factors (medications, high blood pressure, physical activity and others). If bleeding is excessive, call your physician.
  • Allergic reactions to stitches or bandages rarely occur. Please notify us of any known allergies, and be aware that new reactions can also occur. Even with Mohs surgery there is a 1 percent to 2 percent chance that a tumor may regrow. Previously treated tumors and large, longstanding tumors have the greatest risks of reoccurrence after Mohs surgery. Even in these situations, a second Mohs surgery is often the best treatment option.