Mohs surgery is a highly specialized surgical procedure in which a skin cancer is completely removed from the skin surface, or just below the skin surface. It was developed by Dr. Frederick E Mohs in the 1930s to ensure complete removal of skin cancer while leaving behind as much normal skin tissue as possible. In 1967, Dr. Mohs founded the American College of Mohs Surgery (ACMS), a membership organization of more than 1,200 fellowship trained skin cancer and reconstructive surgeons specializing in the Mohs micrographic surgical technique used to treat skin cancer. It is now a very common outpatient procedure performed in the Mohs surgeon’s office.
There are three main steps to Mohs Surgery:
1. The surgical removal of the visible portion of the skin cancer and a thin layer of tissue immediately surrounding. This is called a “stage”.
2. The tissue is processed in the lab and examined under the microscope by the Mohs surgeon.
3. The Mohs surgeon will repeat steps 1 and 2 until the tumor is completely removed and the area will then be repaired.
Specifically, after the planned surgical lines are drawn, the area will be numbed by skin injections using a local anesthetic (usually Lidocaine). Please notify the doctor’s office prior to your surgery date if you have ever had any reaction to anesthetics. Once the specimen is removed by the Mohs surgeon, it will be immediately processed in our on-site pathology lab and 100% of the margins will be checked under a microscope. This process will take approximately 60 to 90 minutes. If there is still tumor (“positive margins“), you will undergo an additional Mohs stage to remove the remainder of abnormal cells. This process will continue until the tumor has been completely removed.
Please note, there are certain types of tumors (i.e. melanoma, sarcomas, other rare tumors) that may call for special laboratory staining methods requiring an overnight processing of the specimen (i.e. “permanent sections”). In these cases, we will perform the surgery, bandage the area and will schedulefollow up. We will repair the area after the final results are received which may take up to one week. This process is necessary due to this type of tumor. Please feel free to discuss any questions directly with our staff or with Dr. Wysong.
When the skin cancer has been completely removed, a decision is made on the best method to repair the wound. The options include but are not limited to:
1. Allowing the wound to heal by itself (granulation)
2. Closing the wound directly (sutures or stitches)
3. Closing the wound with a skin graft or skin flap
4. Outside closure/repair
We will discuss the reconstruction options with you after the tumor is completely removed and will recommend the methods that will be best for your individual care. The majority of repairs are completed by Dr. Wysong, but may also be performed by other surgical specialists. Every one of our patients is unique and we believe in individualizing and optimizing your treatment to achieve results. After the wound is repaired stiches/sutures usually need to be removed about 1-2 weeks after the surgery. This is typically a quick nurse visit to remove the stiches and check the wound.
ADVANTAGES of MOHS SURGERY:
Using microscopic examination, the Mohs surgeon is able to pinpoint the areas involved with cancer and to selectively remove only those areas. The normal skin is left in place and 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. Using the Mohs Surgery technique, the percentage of success is very high, often 97-99%. However, no one can guarantee a 100% chance of cure.
WHAT ARE MY RISKS?:
Any form of surgery will leave a scar. By removing only the tissue involved with cancer and preserving as much normal tissue as possible, the Mohs procedure tends to minimize scarring as much as possible. We will make every effort to obtain the best cosmetic results for you and may work in conjunction with other surgical specialists such as facial plastics, oculoplastics, otolaryngology (ENT) and general plastic surgery as needed. As new skin grows over the wound it may contain more blood vessels than the skin that was removed, particularly as it is healing. This results in a red scar that may be sensitive to temperature changes. The redness of the scar gradually improves with time. However, we also have a specialized vascular laser that can be used to target the redness and treat your scar. This will help the redness to go away more quickly.
Anytime the skin barrier is broken, there is a chance for infection. In Mohs surgery, this possibility is very low. If you have certain medical conditions that make you higher risk for infection, you may be given antibiotics prior to surgery. In addition, depending on the location of your tumor or the type of repair, you may be given antibiotics after surgery. Please call the clinic immediately after surgery if you experience any increasing redness, pain, swelling, or discharge.
In addition, there is a possibility of bleeding after surgery. This risk increases if you take any blood thinners. The most common blood thinners are aspirin, Plavix, Coumadin (Warfarin), NSAIDS (ibuprofen, Aleve, naproxen, etc). Several herbal medications can cause thinning of the blood. Please let your Mohs surgeon know if you are taking any herbal medications or supplements. In addition, alcohol can thin the blood – please avoid alcohol for 24 hours before the procedure and 48 hours after the procedure.
After surgery, you may experience a sense of tightness as the wound heals and this is normal. In addition, you may experience itching. Petrolatum jelly or Aquaphor can help relieve the itching. It is normal to experience some numbness or tingling as your wound heals. It might be one or two years before your sensation returns to normal. In rare cases, this numbness may be permanent. For larger tumors, there is rarely a possibility to damage a motor nerve that can affect movement of your muscles. This possibility will be discussed in detail the day of your surgery if present.
While Mohs surgery has a very high cure rate, there is always a risk for recurrence of the tumor. It will be important to be regularly seen by your dermatologist or Mohs surgeon in three month, six months, and one year after surgery and at least annually thereafter for five years. Studies have shown that once you develop a skin cancer, there is a possibility that you will develop others in the years ahead. We recommend that you see a dermatologist annually for the remainder of your lifetime. Should you notice any suspicious area, it is best to be seen immediately, even if it is between regular appointments.
Filmed, edited, and produced by USC undergraduate student, Taylor Ogden
PREPARING FOR YOUR SURGERY:
· If you have questions or concerns about your diagnosis or the procedure, please call (213) 688-9808 to discuss with us in advance of your appointment.
· Please eat before surgery (unless you are scheduled to go to the operating room and have been told otherwise).
· If you have daily medication, please take them before your surgery unless otherwise instructed. It is not necessary to fast unless you have a closure/repair scheduled for that day which you will be otherwise instructed.
· Arrive for your surgery 15-20 minutes early to allow time for paperwork and to use the bathroom.
· Please note that it is strongly recommended to have someone drive you to and from your procedure, especially if the location of the lesion is near the eye and/or if you receive certain medications.
· There will be a wait as your tissue is prepared for microscopic examination, typically 60 to 90 minutes for each Mohs stage. Depending on your tumor, there may be several excisions and microscopic exams performed in one day with waiting periods. The average number of surgical stages for most skin cancers is two to three. Please feel free to bring books, electronic devices, or other things to help pass the time. We have WiFi in the building. While you are waiting, you may be able go to the cafeteria for some refreshments or walk around a bit (unless you are told otherwise by the doctor or clinical staff). Please leave a good contact number for that day so that we can call you when your results are ready.
· Do not take aspirin, NSAIDS (ibuprofen, Advil, Motrin, Aleve, etc…), vitamin E, or other blood thinners for 1 week before your surgery, unless you are taking these under physician’s advice (eg: for a heart condition). If your doctor prescribed aspirin, continue taking this medication.
o If you normally take Coumadin, Plavix, other blood thinners, let us know at the time you schedule. A recent INR level may be required. PLEASE DO NOT STOP THESE MEDICATIONS.
o Please let us know if you take herbal medicines.
o You may take Tylenol (Acetaminophen) for pain or inflammation.
AFTER YOUR SURGERY:
· Your stitches will be removed in 1-2 weeks. If you live far away or would like to have your stitches removed with your local doctor, please let your doctor know.
· Ice packs or frozen packs (peas, corn, etc.) may be used to help reduce swelling and discomfort.
· For procedures on the lower limb: you will be advised to keep the leg elevated as much as possible when sitting or lying down for 2-3 days. You will want to avoid exercise, excessive walking, or being on your feet for long periods.
· For wounds on the head or face, try to sleep with your head elevated.
· Avoid any activity or movement that causes pulling or stretching of the site for 2-3 weeks after the surgery. (eg: golfing, tennis, weight lifting, running, yoga, etc.)
· Do not swim or submerge for 2 weeks. (eg: bath tub, ocean, pool, hot tub etc.) Showering is fine after 48 hours.
· You will receive post-operative wound care instructions after your surgery. You will usually need to do daily bandage changes until the sutures are removed (about 1-2 weeks, depending on the site).
· You can expect to have mild to moderate soreness and mild clear yellow or blood tinged drainage for 1-3 days after the surgery. Increasing pain, drainage, swelling or redness could be a sign of infection. Report any signs of infection such as redness, swelling, pain and especially fevers and chills to Dr. Wysong or the Mohs team.