Mohs Surgery

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What is Mohs Micrographic Surgery for Skin Cancer?

Approximately 50 years ago Dr. Frederic Mohs developed a technique for the removal of skin cancers that were large and aggressive or had recurred after the original means of treatment. This technique is known as Mohs micrographic surgery.

When is Mohs Micrographic Surgery Used to Treat Skin Cancer?

Although Mohs micrographic surgery can be used to treat the smallest of skin cancers, generally those cancers that are small and have not previously been detected can be removed more easily by other methods such as freezing, scraping and burning, or simply cutting out the cancer and sewing the wound together. Mohs micrographic surgery is usually reserved for those tumors that have recurred after the routine therapy has failed, or for those tumors that are large and send out roots. However, it also may be used for relatively new tumors that have not previously been treated if it is not clear to the physician where the roots of the cancer are.

When the Procedure is Done and What to Expect

Mohs micrographic surgery is usually done as an office procedure under local anesthesia (similar to what your dentist uses to numb your teeth). If possible, alcoholic beverages, Vitamin E, aspirin, and ibuprofen, (Advil, Aleve, etc.) should be avoided for a week prior to your surgery because they increase the likelihood of post-operative bleeding. Tylenol may be taken, if needed.

On the day of your surgery, you may eat breakfast and lunch and take your regular medicines. You should be prepared to rest the entire day. You should also set aside several days in case it takes this long to complete your recovery. Be prepared to spend several hours with us at the office. Bring plenty of reading material or other things that will keep you busy. You will have a significant amount of time to fill. It is always best to have someone drive you to and from the office for surgery. At the least, please make arrangements to have someone available to drive you home, as occasionally this is necessary. We will have snacks and drinks available.

Initially, all the tumor that can be seen with the eye is removed. This is divided into small pieces which are marked with dyes. Lines are marked on the skin to show the source of these specimens. Then a map of the area of surgery is drawn. The pieces of tissue are then processed and examined under a microscope (thus the term “micro-graphic” surgery). Areas still positive for cancer are marked on the map. Surgery is done again on those areas that are still positive for cancer. Once again tissue is removed and examined. After each stage of surgery a dressing is applied. This is then changed when you report for additional surgery. This process is repeated until all areas are free of cancer. Because of this systematic approach there is maximal preservation of normal tissue; in other words, only the cancerous tissue is removed. Also, this approach ensures the highest chance of cure. Each go-around takes about one hour. Therefore, if we have to go through the process three times to clear the cancer, it will take approximately three hours. Depending on the case, it can take significantly longer.

During surgery it may be necessary to cauterize blood vessels. This “seals” them shut and stops bleeding, When we use the cautery, you will hear a buzzing sound or smell an unpleasant odor from time to time. It is a natural reaction to tense your muscles and start breathing quickly when undergoing a procedure. This causes your blood pressure to increase which causes more bleeding. Also, being tense amplifies sensations ten fold and makes it feel like we are doing much more than actually is being done. While we are doing the procedure, it is very important for you to focus on your breathing, taking slow deep breaths. Consciously think of your muscles from head to toe and keep them relaxed and loose.

We never know at the start of Mohs micrographic surgery how large the final wound will be. If we knew this, there would not be a need to do Mohs micrographic surgery since this would mean we knew where all of the roots of the cancer were. Remember, however, that only tissue that needs to be removed is removed.

Stitching or Natural Healing

Some wounds can be allowed to heal naturally while others need to be stitched. Usually this can be done immediately after the complete removal of the cancer. In most cases the stitches are self dissolving. However there are situations when it is best to delay reconstructive surgery for some time. The best management plan for your surgical wound will be discussed when we have completed the removal of the cancer.

Taking Care of the Surgical wound

After surgery, you will be given written wound care instructions. Generally, there tends to be some redness, swelling, and bruising around the wound, but this fades with time. There also may be some drainage of fluid, but this is normal and will decrease with time.

Rarely, bleeding may develop after you have gone home. If this occurs, hold firm steady pressure over the area for ten minutes continuously. Time yourself to make sure you have reached ten minutes of pressure without letting up or peeking. If this fails, repeat the process with ice. This almost always stops the bleeding. If the wound continues to bleed after following the above instructions, you should contact me (Call 602-230-6744). Alcoholic beverages, aspirin products, Vitamin E and ibuprofen should be avoided because they increase the likelihood of bleeding. Generally, there is very little pain following surgery; however, if there is some discomfort, you may take plain Tylenol, two to three tablets every four hours.

Follow-up Care

After the wound is healed you will be returned to the care of your physician. If the cancer is going to come back, it often does so in the first year. Nevertheless, the area of the surgery should be watched for five years. Despite the fact that Mohs micrographic surgery insures a high cure rate, no method is 100% effective and regular check-ups with your doctor are very important.

What to Expect Following Healing of the Wound

After the wound is completely healed, there will be a scar. At first the scar will tend to be red, perhaps even lumpy, feel very tight, and have a drawing sensation. This is normal and may persist. However, all of these signs and symptoms improve with time. At the end of a year, the scar will usually look and feel much better. You should not think of the immediate appearance of your scar as the final result, but look toward a year, or perhaps even longer, for the final cosmetic result.

Because many tiny nerve endings are cut during surgery, numbness may persist, but usually improves over 6-12 months. Also, the area of surgery may remain tender for quite some time and intermittent “shooting” pains or a “crawling” sensation may be experienced. These sensations are due to the nerve endings growing back and are normal.

Cause and Prevention of Skin Cancer

Skin cancer is the most common type of cancer. Fortunately, the most common skin cancer, basal cell carcinoma, tends to remain localized and does not spread to other parts of the body. Squamous cell carcinoma, occurring on sun exposed areas, also usually remains localized but occasionally spreads to other parts of the body. Although Molls micrographic surgery may be used to treat other types of skin cancer, these are the two types of cancer that are most commonly treated with this method.

Although we do not know all the reasons why people get skin cancer, we do know and understand several reasons. By far the most common cause of skin cancer is years of chronic and repeated sun exposure. Those individuals who burn easily, tan poorly, and have fair skin are most susceptible to getting skin cancer as a result of years of sun exposure. Heredity also plays a role and we see families in which many members are affected with skin cancer.

Although we cannot control all factors, one factor which can certainly be controlled is the amount of sun exposure. For the patient who has had skin cancers, sunbathing is not permissible. It is all right to go out-doors and enjoy fishing, golf, tennis, etc., but exposure to the sun should be in moderation and you should use a sunscreen. Generally, people do not think they are getting much sun exposure when going to the car, to the office, or shopping. However, over a period of many years, this certainly can have an adverse effect. Therefore, being careful to avoid accumulative exposure is good prevention. Find a sunscreen that you like to use (SPP 15 is OK, 30 is ideal) and apply it daily to all exposed areas of the skin. A wide-brimmed hat is helpful in providing shade to the scalp and face. Lastly, activities that one does regularly such as yard work are best done in the morning or evening hours. The sun is at its most intense between 10am – 4 pm.