What is Mohs Surgery?
Mohs micrographic surgery is a highly specialized procedure for the removal of skin cancer. It was originally developed in the 1930’s by Dr. Frederick Mohs and has been refined since, gaining substantial application only in the past decade. Although this procedure is very precise, its major drawback is that it is very time consuming, and requires specialized training, personnel, and equipment. Consequently, only a few major medical centers can provide this type of therapy.
General Surgery Information
Advantages of Mohs Surgery
Unlike microscopic examination, with the advanced Mohs techniques, our surgeons can pinpoint areas involved with cancer and selectively remove only those areas. In this way, the skin cancer is traced out to its “roots.” This results in preserving as much normal tissue as possible with the highest chance for cure. Other forms of therapy have only a 50% to 70% chance for success in curing skin cancers that have previously been unsuccessfully treated. Using the Mohs micrographic surgery techniques, the percentage of success is very high, often 97%, even when other forms of treatment have failed. With this technique, an excellent chance of cure is achieved. However, no one guarantees a 100% chance of cure.
Our surgeons are thoroughly convinced that the advanced Mohs technique is the best way to provide his patients with the highest chance for cure while preserving the maximum amount of normal tissue. When facing the most complex and challenging skin cancer cases, the Mohs techniques are proven to be the best response. It is highly specialized, and not all medical centers in the United States are equipped with the personnel and training to offer this treatment.
Our surgeons frequently receive patients who are referred for Mohs surgery after other forms of treatment have failed. This does not mean that the patient is cancer prone or a particularly hopeless case. It merely means that the methods used for treatment in the past did not destroy all the skin cancer cells. Because Mohs micrographic surgery uses complete microscopic control to search out the “roots” of the cancer, it cures almost all patients – even those in whom skin cancer has persisted in spite of several other treatments.
3 Surgical Steps to Mohs Surgery
- The surgical removal of the visible portion of skin cancer.
- The surgical removal of a thin layer of tissue at the bed of the cancer.
- The examination of the excised tissue layer under the microscope.
By examining the edges and underside of the tissue, our surgeons are able to trace out and exactly locate any additional areas of cancer remaining. Before the tissue is examined, it is marked with colored dyes to distinguish top from bottom
and right from left, and a detailed map of the excised tissue is made. By doing this, we are able to pinpoint the exact location of any remaining tumor during the microscopic examination. If more cancer is present, the procedure is repeated.
Only the area of the remaining cancer is removed.
Outpatient or in the Hospital?
Whenever possible, the surgery is performed as an outpatient in the Plano, Texas clinic. Occassionally, it is required that you stay in the hospital. We will inform you if we feel it would be best for you to be hospitalized at the time of you initial visit. Occasionally, patients must be hospitalized after treatment to allow follow up or reconstruction.
Before the Surgery
Preparing For Your Surgery
The preoperative visit allows our surgeons the opportunity to examine your skin cancer, obtain medical history, and determine whether the technique of Mohs micrographic surgery is the most suitable way of treating your skin cancer. Also, it gives you an opportunity to learn about the procedure. Every skin cancer is different, and because of the high demand for and extended nature of Mohs micrographic surgery, careful scheduling is necessary. A date for surgery that is mutually acceptable will be arranged. When patients are referred to us, usually a biopsy (removal of a piece of tissue) has been performed and a pathology report stating the type of skin cancer is available. If we do not have this information, a biopsy is performed at the initial visit. The skin cancer and surrounding skin will be photographed before and immediately after healing. The photographs become part of the medical record and may be used for teaching purposes.
Getting Ready for Mohs Micro Graphic Surgery
Try to get a good night’s rest and eat a good breakfast. If you are taking any medications, take them as usual unless directed otherwise. We request that you do not take any aspirin or aspirin containing products such as Anacin or Bufferin for two weeks prior to the surgery. These medications “thin” your blood and cause more bleeding. We also ask that you not drink any alcoholic beverages in the two days prior to surgery. Alcohol causes blood vessels to dilate and aggravates bleeding problems. Tylenol or acetomenaphen is permitable to take.
It is a good idea to bring a book or magazine with you on the day of surgery. The procedure may take a full day, much of which you will spend in the waiting room. It may be relaxing to have company while you are sitting in the waiting room. It is recommended that you have someone drive you home. We prefer that you limit the number of people accompanying you to one or two persons because of limited space in our waiting room. No young children please.
Day of the Surgery
Plan for Surgery
Surgery is usually scheduled early in the day. When you arrive for surgery, the surgical assistant will take you to the surgery suite and prepare the involved area of skin for surgery. If you have any additional questions, feel free to ask them. Dr. Hollobaugh will then anesthetize the area of skin containing the cancer. The anesthetic agent is given locally by a small shot (needle). After this tissue has been removed, the bleeding will be stopped. Before you leave the surgical suite, the surgical assistant will cover the wound with a bandage. The tissue will be sent to the laboratory for examination. It usually takes 30-45 minutes to anesthetize the involved area and to remove the tissue. You will then have to wait while the tissue is processed for examination, stained, and examined by the doctor. This process varies from 30 minutes to an hour or more. Do not leave the waiting room without checking with the desk. If examination of the tissue removed reveals that you still have some cancer cells, the procedure will be repeated as soon as possible. Several excision and microscopic exams may be done in one day. It is occasionally necessary for you to return the following day for additional surgery. The average number of surgical sessions for most skin cancers is two or three, so most patients have their entire skin cancer removed by midday.
After the Surgery
The Surgical Wound
When the skin cancer has been completely removed, a decision is made on the best method for treating the wound created by the surgery. These methods include:
- Closing the wound with stitches.
- Letting the wound heal by itself.
- Closing the wound with a skin graft or flap.
Our surgeons will recommend which of these methods will be best for your individual case, and you will decide which option you desire. Repairs may be completed by us or by other surgical specialists. Each patient is unique and we must individualize your treatment to achieve the best results. You may experience a sensation of tightness (or drawing) as the wound heals, but this is normal. As time progresses, you will feel this less and less. Frequently, skin cancers involve nerves and it may be one or two years before sensation returns to normal. In some cases, the numbness may be permanent. Any form of therapy will leave a scar. the Mohs micrographic surgery procedure tends to minimize scaring as much as possible. Our surgeons strive to remove only those tissues involved with cancer and preserve as much normal tissue as possible. We make every effort to obtain the optimal cosmetic results for you and work in conjunction with other surgical specialists, but our primary goal is to remove the tumor.
The new skin that grows over the wound contains many more blood vessels than the skin that was removed. This results in a red scar and the area may be sensitive to temperature changes. This sensitivity improves with time and the redness gradually fades. If you are having a lot of discomfort, avoid extreme temperatures. You may experience itching after your wound is healed. Moisturizers help relieve the itching. The healing process goes on for a long time and may take 6 to 18 months to be complete.
A follow up period of observation for five years is necessary after the wound is healed. You will be asked to return in four to six weeks, then in three months, six months, and annually thereafter. Your follow up may be handled by the physician who referred you to our surgeons. Should there be any recurrence of the skin cancer after the surgery, it may be detected at once and treated. Experience has shown that if there is recurrence, it usually will be within the first year following surgery.
Sun Exposure after Surgery
We do not think that sunshine is harmful to you as long as you use adequate protection, avoid burning, and use discretion. As mentioned, sunlight is probably the main contributing factor in the development of skin cancer, and patients who have developed one skin cancer often will develop more at a later time. When you go into the sun between the hours of 10 A.M. to 4 P.M., our surgeons recommend that you liberally apply a sun screen with SPF 15 to all exposed areas, including the tops of your ears. It is best to apply the sun screen about 15-30 minutes before going outdoors. Be sure to reapply it liberally after swimming or exercising since sun screens can wash off with water or perspiration. In addition to a sun screen, you should wear a broad rimmed hat and utilize clothing to further protect yourself from the sun. You may lead a normal life style if you take precautions, and are sensible.