Mohs Surgery & Skin Cancer
What is Mohs Micrographic Surgery?
Mohs surgery is a highly specialized treatment for the total removal of skin cancer. This method differs from all other methods of treating skin cancer by the use of complete microscopic examination of all tissues removed surgically, as well as detailed mapping techniques to allow the surgeon to track and remove all of the roots and extensions of the skin cancer. Mohs surgery is most useful in treating skin cancers that demonstrate growth patterns which have a high risk of recurrence or are located in cosmetically sensitive areas such as the face, nose, ears, and eyelids.
What is the cure rate?
Mohs surgery is the most accurate method for removing skin cancers, even when previous forms of treatment have failed. In previously untreated cancers, the cure rate with Mohs surgery is 99 percent. In previously treated cancers, where other forms of treatment offer only an 80 percent chance of success, Mohs surgery is 95 percent effective.
As tumors are often larger than their surface appearance indicates, the wound after complete removal of the cancer may be larger than anticipated. Our primary goal is to remove the entire tumor.
We make every effort to obtain an optimal cosmetic appearance after surgery. With any excision-surgical procedure, scarring will occur at the site of removal.
Occasionally, the surgical site may be slow to heal, grafts or flaps may fail, or the repair may reopen after closure. The most common risk factors for these include smoking, diabetes, bleeding, poor physical condition, or other disease states.
Skin cancer frequently involves nerves. With removal of the skin cancer, there may be local numbness, or less common, loss of local muscle movement after the procedure. Occasionally, nearby nerves, sensation will usually return over a time period of up to 24 months: Motor nerves are less likely to have a return of function. For damage to major motor nerves, microsurgical repair may be required to salvage function.
No procedure can guarantee that the cancer will never return. With Mohs surgery, however, your cure rate will be maximized.
Although infection is rare (less than 1%), it can occur. Make sure that you follow your wound care instructions carefully and care for your surgical site on a daily basis.
How can future skin cancers be prevented?
The best protection from skin cancer is to avoid the harmful ultraviolet rays of the sun. Even if you tan easily, the sun can contribute to skin cancer. Minimize your exposure by
- using a sunscreen with a sun protective factor (SPF) of at least 30 when you spend any time in the sun,
- wearing broad brimmed hats,
- minimizing sun exposure during midday hours (10 am to 2 pm), and
- using sun protection even on cloudy days since the ultraviolet light penetrates easily through the clouds. With adequate protection, you should be able to enjoy most of your normal daily activities without significantly increasing your risk of future skin cancers.
Post-surgical care and healing:
Your surgical wound will require care during the week(s) following surgery.
Will the surgery leave a scar?
Yes. Any form of treatment will leave a scar. However, because Mohs surgery removes as little normal tissue as possible, scarring is minimized. Also, complete healing of the surgical site may take up to 12 months. During this time, the surgical site may appear reddened or may feel swollen or lumpy, particularly in the first few months.
Will I have pain or bruising after surgery?
Most patients do not complain of pain. If there is any discomfort, Tylenol is all that is usually necessary for relief. Avoid taking medications containing aspirin as they may cause bleeding. You may have some bruising around the wound, especially if the surgery is close to the eye.
Will further procedures need to be done?
Most patients will not require further procedures after the repair of their surgical defect. Some repairs are completed in two stages, with the second stage occurring two to three weeks after the initial surgery. Also, in a minority of patients, some postoperative modification of the surgical site may be performed 6-8 weeks after the primary surgery to optimize the surgical outcome. Occasionally, depending on the type of cancer and its extent, postoperative radiation therapy may be recommended after surgery.
Usually only one or two return visits are needed to remove stitches or examine the healed surgical site. Afterwards, you may return to your referring physician for routine check-ups. A follow-up period of five years for the treated cancer is essential. After having one skin cancer, statistics show that you have a higher chance of developing a second skin cancer. You should have your skin checked by your referring physician at least once a year, not only to examine the treated skin cancers, but also to check for new skin cancers.
Risks associated with Mohs Micrographic Surgery
Although your surgeon will remove as little tissue as possible, there are some general risks associated with the surgery. Your doctor will discuss these and any additional problems associated specifically with your situation.
On the day of surgery
- Eat a good breakfast.
- Take your usual prescribed medications, unless you have been directed otherwise.
- Take any preoperative medications that we may have prescribed for you.
- Wear loose-fitting clothing. We recommend clothing that can be unbuttoned and removed.
- You may need to bring someone to drive you home. However, we recommend that you only bring one person due to space considerations in our waiting room.
- Plan to arrive at least 15 minutes early so that a medical chart can be prepared.
The removal of the skin cancer
Your appointment will be scheduled early in the day. Our staff will escort you into a surgical suite where you will have the area around the skin cancer numbed. Once it is numb, the visible cancer and a thin layer of tissue will be removed. This tissue is carefully mapped and coded by the surgeon and taken to the adjacent laboratory where the technician will immediately process the microscopic slides. You will have a temporary dressing placed over the wound and you will be able to return to the waiting room.
The surgical procedure alone takes only 10-15 minutes. However, it takes a minimum of 60-90 minutes to prepare and microscopically examine the tissues. Several surgical stages and microscopic examinations may be required, and you will be asked to wait between stages. Although there is no way to tell before surgery how many stages will be necessary, most cancers are removed in 3 stages or less.
We would like to make the time you spend with us as pleasant and comfortable as possible. You may want to bring reading material to occupy your time while waiting for the microscopic slides to be processed and examined. Magazines will be available in the waiting room area.
The most difficult part of the procedure is waiting for the results of the surgery. Since we do not know in advance how much time is necessary to remove the cancer and repair the wound, we ask that you make no other commitments for the entire day on which you are scheduled for surgery.
The reconstruction after the cancer is removed
Immediately after the cancer is removed, we may choose 1) to allow the wound to heal by itself, 2) to repair the wound with stitches or a skin graft or flap, or 3) to send you to the referring physician or another surgical specialist for wound repair. The decision is based on the safest method that will provide the best cosmetic result. When the reconstruction is to be completed by another surgical specialist, it may take place on the same day or a subsequent day. It is not harmful to delay the reconstruction for several days. Occasionally, this reconstruction may require hospitalization.
Is hospitalization necessary?
No. Mohs surgery is performed in our office and you may return home the same day.
Will my insurance cover the cost of surgery?
Most insurance policies cover the cost of Mohs surgery. However, you should check with your carrier for exact information related to their schedule of payments. On your first visit please bring a copy of your I.D. card and insurance card.
Mohs Micrographic Surgery – How it works (the preoperative visit)
You may be asked to have a preoperative visit prior to undergoing surgery. This visit will give you the opportunity to meet your doctor and his medical staff, and learn more about Mohs Micrographic Surgery. An examination of the cancer will be performed and a medical history will be obtained. Occasionally, some preoperative tests will be ordered. Reconstruction options may also be discussed. You will have the opportunity to ask any questions you have relating to your upcoming surgery.
Preparation for surgery
It is important that you are as comfortable, relaxed and informed as much as possible when you arrive for surgery.
- Ask any questions that you may have.
- Continue any medications prescribed by your doctor. However, aspirin is a drug that may prolong bleeding. We ask that you avoid aspirin (including Anacin, Bufferin, Excedrin, Alka Seltzer and Percodan) for 10 days prior to surgery, so long as your doctor did not specifically prescribe the aspirin for a medical condition (e.g. stroke, heart disease, coronary stent, etc.).
- Discontinue any vitamin E supplements (multivitamins are okay) for 10 days prior to your surgery.
- If you take coumadin, we ask that you have its level checked within one week of your surgery.
- If you smoke, try to cut down or quit prior to your procedure and for at least two weeks afterwards.
- Do not drink any alcoholic beverages 48 hours prior to surgery, or 24 hours following the procedure.
- As you may not be able to shower for 24 hours after your surgery, you may wish to shower the night before or the morning of your procedure.
- Although most people are in the office for a few hours, we recommend that you plan for the possibility of spending the entire day with us.