Mohs Surgery

Introduction Over 30 years ago, Dr. Frederic Mohs developed a technique for the microscopically controlled removal of problem skin cancers. Mohs surgery is done under local anesthesia and rarely requires hospitalization. The Mohs procedure is extremely precise demonstrated by the very high cure rate, (99% of first time skin cancers, and 95%-97% of skin cancers that have come back). The drawbacks are that it is somewhat time consuming and requires specialized training, personnel, and equipment, but it is well worth the trouble. Note: Make sure your physician is Mohs fellowship trained. There are physicians out there that perform the procedure without the full year or two of fellowship training.

This page attempts to answer some of your questions you may have as a patient. We expect and welcome further questions about the surgery.

What is Skin Cancer? Cancer is tissue that grows at an uncontrollable and unpredictable rate. The types that we most commonly treat with Mohs surgery are basal cell carcinoma and squamous cell carcinomas, along with some other very rare skin cancers. Skin cancer begins at the surface of the skin and grows roots downward. What can be seen of the cancer on the surface is usually only the "tip of the iceberg."

Is it Dangerous? Skin cancers that we treat with Mohs surgery usually do not spread to other parts of the body and cause death. They can, and often do, destroy the skin and structures where they grow and locally spread. A skin cancer left untreated long enough can cause death if it invades into a vital structure. These skin cancers do not go away on their own! Though they may seem to heal over, if untreated, they always come back bigger, and with deeper roots. While the removal of skin cancer is not an emergency, in general they should be removed within a month or two of diagnosis.

What Causes Skin Cancer? No one is certain of all the causes of skin cancer. Several factors, most importantly is sun exposure, seem to interact together to make some people more susceptible. People with very fair skin, light or red hair, and blue eyes definitely get skin cancer most often. Heredity does seem to play a part, with some families having more skin cancer than others. Other possible causes of skin cancer include X-ray therapy, given in the past for acne, old burn scars, and certain patient medicines such as Fowler's solution and Paris Green insecticide, both of which contain arsenic.

Will My Insurance Pay For Mohs Surgery? Yes, almost always. Mohs surgery is time consuming and labor intensive. You are responsible for any deductible and 20% copayment if required, although if you have a secondary policy it is almost always covered. We like to arrange for your insurance company to reimburse us directly if possible. If this is a hardship, let us know, and we will work out an alternative plan. If you are a Medicare enrollee, be sure to mention any special supplemental policies to the front desk secretaries. Also, bring any insurance cards and policy numbers with you.

How May Skin Cancer Be Treated? There are a variety of successful methods of treating most skin cancers in most people. These include scraping and burning, cutting out and sewing up, x-ray treatment, and cryosurgery (freezing). Mohs skin cancer surgery has a superior cure rate, and often times is performed after a prior treatment has failed. It is important to emphasize however, that no method at any time, including the Mohs technique, can promise 100% cure rates.

Why Bother With Mohs Surgery? Mohs surgery cuts out the bare minimum of normal skin needed for a high cure rate (95%-99%). This is important in critical areas. Once a tumor has come back, conventional treatment (cutting out, scraping and burning, radiation) offers only a 50% cure rate. Mohs surgery is worth the bother in order to get all the cancer out and to get the smallest possible hole.

Will I Need To Be Hospitalized? No, probably not. Only rarely do Mohs surgery patients need to be hospitalized. Whenever possible, Mohs surgery is done on an outpatient basis. We can, however, hospitalize patients if they need it.

What about the Wound hole? When it is determined that your cancer has been completely removed, there will be a hole left where it was. A decision will then be made on the best way to manage this wound. If it is small, it may be allowed to heal on its own. It may also be sewn shut, or be repaired with a skin graft or flap. Some wounds are best handled by a plastic or reconstructive surgeon. The method used depends on many variables. In many cases, the repair may be arranged to be done by a specialist before the Mohs surgery. You will be given a detailed instruction sheet on how to care for your wound at the conclusion of the surgery.

Will There Be A Scar? Yes. Any treatment of skin cancer will leave a scar. Mohs surgery preserves as much normal skin as possible resulting in a scar as small as possible.

How Do I Prepare For Mohs Surgery? Try to get a good night sleep, eat breakfast, and get to the office on time. Wear comfortable clothing that you can easily get in and out of. We often get all the cancer out by noon, but we recommend to bring a book and a friend. Take your usual medicine unless we tell you otherwise.

Does It Hurt? A local anesthetic, usually Xylocaine, is injected around the skin cancer to numb the area. This burns only a little and the numbness lasts several hours after injection. More Xylocaine maybe injected later so that there is no pain if more surgery is required. Pain after going home is unusual, and two regular Tylenol, by mouth every four hours, is usually adequate for any pain.

Should Someone Come With Me On The Day Of Surgery? Do I Need Someone To Drive Me Home? Yes, I suggest you do bring someone with you to drive you home and keep you company during the procedure. If this cannot be arranged, public transportation or a taxi may be adequate. Do not count on driving yourself. If you receive a sedative, or have a skin cancer near your eye, you will not be able to drive.

What Happens On The Day Of Surgery? Appointments for surgery are usually scheduled early in the day. It is important to be on time. You will be escorted into the operating room. The cancer may be outlined with a marking pen, and then a local anesthetic is injected to numb the skin. The next step is to remove a thin layer of skin around the cancer. This tissue is carefully removed. The bleeding is stopped with a cautery machine. This machine makes a buzzing sound and generates heat which stops the bleeding. The nurse will then bandage you. By the time you get to the waiting room the removed tissue is already in our laboratory being processed for microscopic examination. The most difficult part is waiting for the results of the surgery. This usually takes about an hour, though it may take longer.

If the microscopic examination reveals that your tissue still contains cancer, the operating room procedure is repeated and the tissue again examined. Only the tissue containing skin cancer is removed. Several trips in and out of the surgery room may be required the day that you are here.

What About Bleeding After Surgery? Uncommonly, about one in 200 patients, there is some bleeding after you go home. If this occurs, lie down and apply steady firm pressure over the wound as close as possible to the area that is oozing blood. Apply this pressure continuously for 15 minutes (time it). While applying pressure, do not lift the bandage to check for bleeding. If the bleeding persists after 15 minutes of steady pressure, call Dr. Adelman at (305) 606-3303, or go to the nearest emergency room.

If the bleeding stops after 15 minutes, (as it almost always does), you may apply an additional layer to the dressing until the following day when you clean the wound.

What Else May Happen? All wounds develop a small ring of redness which will gradually disappear. Severe itching with extensive redness usually indicates an allergy to the ointment used to dress the wound or a reaction to the adhesive tape. You should call the office if this happens.

Swelling is common after Mohs surgery, especially around the eyes. This is a normal response. You may develop bruises around the area of surgery.

Initially all wounds drain a clear or pink tinged fluid which is normal. Infection is unusual. If the wound has been left to heal on its own, as is sometimes done, a thick yellowish discharge will develop by the second week. This is not pus but rather dead tissue separating from the base of the wound. As this separates, there may be a light amount of bleeding.

What Happens After The Wound Heals? You may feel a sensation of tightness (or drawing) as the wound heals, but this is normal and will lessen as time goes on. Frequently, skin cancers involve the nerves of the skin making it necessary to cut the nerves. It may take a year or more after surgery before the feeling returns to normal. Sometimes the area stays numb permanently. Much less commonly, one of the several nerves that control the muscles of the face are involved with the cancer. Every attempt is made not to damage these nerves but sometimes they must be cut out to get the cancer out. This may result in a temporary or permanent paralysis of certain muscles of the face. If permanent paralysis occurs, there are restorative surgical procedures that can be performed.

The new skin that grows over a 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 (such as cold air). This sensitivity improves with time, and the redness gradually fades. If you are having a lot of discomfort, try to avoid extremes of temperature.

The new skin lacks the ability to protect itself from the sun so it will blister readily with increased sun exposure. You must protect it with a sunscreen (factor 15 or higher) at all times.

Patients frequently experience itching after their wounds have healed because the new skin that covers the wound does not contain as many oil glands as previously existed. Applying a small amount of Vaseline will help relieve this itching.

How Often Must I Return For Follow-Up Visits Once The Wound Has Healed? After the stitches come out we usually like to see you two months later. A period of observation of 5 years is essential. This follow up can be done by your Dermatologist. There are several reasons why this is important.

Should there be a recurrence of the skin cancer after Mohs surgery, it may be detected at once and treated. Experience has shown that if there is a recurrence it will usually be within the first year following surgery.

Studies have shown that once you develop a skin cancer there is a high risk that you will develop others in the years to come. You should watch for an open sore which does not heal and bleeds easily. If you notice any suspicious areas it is best to check with your referring physician to see if a biopsy is indicated.

Must I Totally Avoid The Sun? No, not entirely. Sunshine cannot harm you as long as you are protected; avoid burning, and use discretion. You should not restrict your activities to the degree that it would interfere with your lifestyle.

Sunlight is probably the main cause of skin cancer. I recommend you apply a factor 15 or higher number sunscreen to all exposed areas for incidental exposure. Because the sun is the most direct cause of non-melanoma cancers, Dr. Adelman recommends wearing your sunscreen before going outside, at least SPF 15 for incidental sun exposure and SPF 30 and over for prolonged exposure like golfing or boating, although protective clothing is even better. Also avoid the sun between the hours of 10 a.m. to 4 p.m. when the sun intensity is the greatest It is important that men and women remember to include the tops of their ears, and men cover their bald spots.

I hope this information has answered many of your questions. If you have further questions do not hesitate to ask.