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Mohs Micrographic Surgery

If your doctor has recommended that you undergo Mohs micrographic surgery for treatment of your skin cancer:

This is a specialized technique of skin cancer removal that offers the highest available cure rate as well as allowing preservation of normal tissue. It is performed as an outpatient and requires only local anesthesia (numbing shots).

Why did my doctor recommend Mohs surgery to treat this skin cancer?

Although there are many effective forms of treatment for skin cancer, your doctor has decided that certain characteristics of this skin cancer warrant the extra benefit of Mohs micrographic surgery.

The size, type, location, and history of prior treatment of the skin cancer are all important factors your doctor considered when deciding upon Mohs surgery as the preferred method of treatment. Patient desire for maximum cosmesis after treatment is also an important consideration. Additionally, some patients have conditions that make them more susceptible to skin cancer that could spread to other parts of their body. In summary, your doctor has carefully decided that Mohs surgery will provide the best treatment outcome for your skin cancer.

Why does Mohs surgery offer the highest cure rate?

Skin cancers, such as basal cell and squamous cell carcinoma, tend to grow in the skin in a configuration much like your hand. They have a central bulky portion with “fingers” that can extend deeper and to the sides. If the tumor extensions are not completely removed, the tumor can grow back and require more extensive surgery at a later date. Mohs surgery allows microscopic confirmation that each of these “fingers” has been removed prior to repair of the area.

Certain areas of the head (face, eyelids, lips, nose, ears, and scalp), neck, and back of the hands have less fat and muscle that prevents the tumor from invading important underlying structures. Early and complete removal in these areas is necessary to prevent damage to nerves, blood vessels, muscle, cartilage, and bone.

Mohs surgery offers the highest cure rate for tumors that have recurred after previous treatment. Recurrent tumors behave more aggressively and complete removal is imperative to minimize their destruction. Additionally, they are more difficult to completely remove with conventional methods.

There are numerous types of skin cancer that occur less commonly than basal cell or squamous cell carcinoma. Many of these behave aggressively. Early and complete removal of these types is essential to both reduce destruction of local tissue and spread to other parts of the body.

How is Mohs surgery performed?

The procedure is done in an office setting under local anesthesia (numbing shots). First, the visible portion of the tumor is removed and transported to the laboratory. This only takes about five minutes. In the lab, the tissue is systematically marked and frozen and then slides are prepared by a staining process. The slides are then reviewed under the microscope by the Mohs surgeon. If tumor buds are seen on the slide, the Mohs surgeon marks the location on the Mohs map. The Mohs surgeon then uses the map to correlate precisely where they are located on the patient’s defect. The slide preparation and review process takes about 45 to 60 minutes. The patient is sitting comfortably during the waiting period and is free to read, eat or listen to music. If tumor buds were located, a subsequent stage of tissue removal is performed. This is commonly referred to as “tracking the root”. This process is repeated until no more tumor is detected under the microscope. (Figure 1)

Once complete removal of the tumor has been confirmed, the patient will be transferred from a staging room to a procedure room to repair the defect. Defects can be repaired by letting the defect heal in on its own (“second intent”) or using reconstruction techniques with sutures. Reconstruction techniques offer a better functional and cosmetic result in most tumor locations. Defects can be reconstructed by linear closure, flaps or grafts. Linear closure is the most common method used and involves removing a triangle of tissue from each end of the defect so that the suture line will lie flat when healed rather than having “puckered” ends. A flap will offer a better reconstruction result in some instances. Flaps are performed by making additional cuts to release adjacent tissue that is then sutured into the defect. Rarely, some defects require that skin be removed from a remote location such as from around the ear or collar bone to be sutured in place. This is known as a graft.

Your Mohs surgeon will decide which reconstruction technique will offer the best functional and cosmetic result. Because the procedure is done under local anesthesia, you will be actively involved in this decision process.

What are the surgeon’s qualifications to perform Mohs surgery?

Michael Webb, MD is the Mohs surgeon at Tennessee River Dermatology. Dr. Webb has completed over 11,000 cases of Mohs micrographic surgery and reconstructions. He is board certified in dermatology and has completed a fellowship in dermatologic and Mohs surgery at Vanderbilt University. He is a fellow in the American Society of Dermatologic surgery and was elected into the American College of Mohs Surgery. He authored several articles that have been published in national journals as well as a chapter in a leading textbook on Mohs Surgery.

Tennessee River Dermatology received the three year “Gold Seal” accreditation for office based surgery from the Joint Commission. This award was given in recognition of Tennessee River Dermatology’s extraordinary commitment to provide safe, high quality care and a willingness to be measured against the highest national standards of performance.

How should I prepare for Mohs surgery?

A few preparations are necessary for a smooth Mohs surgery. These will also be discussed at your pre-operative consult visit.

Medicines that will “thin the blood” should be withheld for 10 days prior to your surgery. Common medicines known to do this are aspirin containing products, arthritis medicines and blood thinners. Table 1 lists “blood thinning” medicines that are commonly used. Make sure to check with your prescribing physician that it is alright to withhold these medicines for 10 days before and 2 days after your surgery. Do not stop these medicines without your prescribing physician’s approval. Limit alcohol intake 48 hours prior to surgery as this can also “thin the blood”.

You should come to your surgery with a driver. You will only receive local anesthesia, but some post-op bandages and swelling can impede your vision. You should not schedule any other appointments that day. Mohs surgery usually takes 3 hours but could require 6 hours or more it the tumor is extensive.

Plan your schedule so you can take it easy for 5-7 days afterward. Activities that would move or stretch the surgery site such as exercise, yard-work, house-work or lifting should not be performed for 1 week after your surgery.
Smoking drastically impedes healing from skin surgery. If you smoke, either stopping completely or reducing your tobacco consumption by one half is highly recommended.

What can I expect after my procedure?

You will leave the office with a bulky pressure bandage in place. This should remain in place for 48 hours. This will minimize the minor swelling and bruising that usually develops during this period. When you remove your pressure bandage, your wound will appear raised and bumpy. This is normal. If outside sutures were used, these will be removed in about a week. Your wound will remain elevated and pink for about 6 weeks. After 6-8 weeks the wound will begin to flatten out. The suture line will remain pink for about 6 months then fade to a flesh color.

You will be sent home with detailed written instructions regarding how to care for your wound. The cosmetic outcome of your surgery largely depends on how well you follow these written instructions. Some people form excessive scars that may require injections, sanding or further surgery. Your healing response will be assessed at a 2 month post-op visit.

Why must I have a “pre-operative consult”?

A brief medical examination is necessary to identify patients with conditions that might require pre-operative antibiotics, changes in their medicine regimen or limit the use of cautery. Additionally, it will allow the patient to become familiar with the building location, the facility, the staff and the surgeon. An opportunity to examine the cancer before surgery will improve the surgeon’s ability to schedule the appropriate amount of time and prepare the patient for the probable type of closure.

Why must I have a biopsy before I have Mohs surgery?

A recent biopsy is necessary to confirm your doctor’s suspicion that your lesion is indeed a skin cancer. Additionally, Mohs surgery is not warranted for many types of skin cancer. In most instances, your doctor used the information obtained from this biopsy before deciding that Mohs surgery was the best treatment option for your skin cancer.

Does Mohs surgery cost more than other types of skin cancer surgery?

Mohs surgery is one of the most cost-effective forms of treatment for skin cancers. Although the cost of Mohs surgery appears higher on a bill or a statement, skin cancers treated with Mohs surgery actually save patients, insurance companies and Medicare money. This is because many “associated costs” of treatment are included in the Mohs micrographic surgery and repair fee.

Hospital or surgery center fees are eliminated because Mohs surgery and repair is performed in the office. There are no additional pathology (lab report) costs because these are included in the Mohs surgery fee. Additionally, the exceptional cure rate Mohs surgery offers greatly reduces costs of “re-treating” the same skin cancer. As a result, Mohs micrographic surgery is considered the most cost-effective treatment for certain skin cancers.

Can the Mohs surgeon treat my other skin lesions at the same time?

Your doctor is your skin specialist. Your Mohs surgery appointments are dedicated toward specific treatment of the skin cancer your doctor has detected. Your doctor has a thorough understanding of all of your skin and your history. Other lesions should only be treated by the Mohs surgeon as directed by your doctor.

Occasionally, the Mohs surgeon may treat two or more skin cancers at the same surgery visit. This depends upon the tumor location, size and type. In general, it is preferable to perform one surgery per visit.

In summary, Mohs surgery is a safe, effective method of treatment for your skin cancer that provides the highest cure rate and maximum cosmetic outcome.