What is Mohs Surgery?
There are five standard methods for treatment of skin cancers. The two nonsurgical treatments are cryotherapy (deep freezing) and radiation therapy. The three surgical methods include simple excision, physical destruction (curettage with electrodesiccation) and Mohs micrographic surgery. Newer methods of investigation include photodynamic therapy and immunochemotherapy.
In the past, Mohs Micrographic Surgery was sometimes called chemosurgery or Mohs chemosurgery. Originally, chemicals were applied to the skin during the surgery and hence, the name chemosurgery. Chemicals are now rarely used, but the name chemosurgery continues to be associated with the procedure.
After the removal of the visible portion of the tumor by excision or curettage (debulking) there are two basic steps to each Mohs Micrographic Surgery stage. First, a thin layer of tissue is surgically excised from the site. This layer is generally only 1-2 mm larger than the clinical tumor. Next, the tissue is processed in a unique manner and examined underneath the microscope. On the microscopic slides, Dr. Conti examines the entire bottom surface and outside edges of the tissue. (This differs from the “frozen sections” prepared in a hospital setting which, represents only a tiny sampling of the tumor margins.) This tissue has been marked to orient top to bottom and left to right. If any tumor is seen during the microscopic examination, its location is established, and a thin layer of additional tissue is excised from the involved area. The microscopic examination is then repeated. The entire process is repeated until no tumor is found.
Mohs Micrographic Surgery allows for the selective removal of the skin cancer with the preservation of as much of the surrounding normal tissue as possible. Because of this complete systematic microscopic search for the “roots” of the skin cancer, Mohs Micrographic Surgery offers the highest chance of complete removal of the cancer while sparing the normal tissue. The cure rate for new skin cancers exceeds 97%. As a result, Mohs Micrographic Surgery is very useful for large tumors, tumors with indistinct borders, tumors near vital functional or cosmetic structures, and tumors for which other forms of therapy have failed. No surgeon or technique can guarantee 100% chance of cure.
What is Skin Cancer?
Skin Cancer is by far the most common malignant tumor in humans. The most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Both basal cell carcinoma and squamous cell carcinoma begin as a single point in the upper layers of the skin and slowly enlarge, spreading both along the surface and downward. These extensions cannot always be directly seen. The tumor often extends far beyond what is visible on the surface of the skin. If not completely removed, both types of skin cancer may invade and destroy structures in their path. Although these skin cancers are locally destructive, they do not tend to metastasize (spread) to distant parts of the body. Metastasis of basal cell carcinoma is extremely rare and usually occurs only in the setting of long-standing large tumors where the patient’s immune system is compromised. Squamous cell carcinoma is slightly more dangerous, and patients must be observed for any spread of the tumor. Such spread is still infrequent. Melanoma is a very different and more dangerous kind of skin cancer and is occasionally treated with Mohs Micrographic Surgery.
Excessive exposure to sunlight is the single most important factor associated with the development of skin cancers. In addition, the tendency to develop these cancers appears to be hereditary in certain ethnic groups, especially those with fair complexions and poor tanning abilities. Fair-skinned people develop skin cancers more frequently than dark skinned people, and the more sun exposure they receive, the more likely they are to develop a skin cancer. Other factors, including exposure to radiation, trauma and exposure to certain chemicals, may also be involved in the development of skin cancers.
The vast majority of skin cancers are present for more than a year before being diagnosed and their growth is rather slow. Skin cancers may be more aggressive in certain instances; patients whose immune system is compromised, patients with a medical history of leukemia or lymphoma, cancers in certain locations such as the ear, lips, lower nose, or around the eyes.
Be well rested and eat a good breakfast. Take your usual medications, unless directed otherwise. We request that you do not take any aspirin or aspirin containing products, such as Anacin, Bufferin, Ibuprofen (Motrin, Advil, etc.) for ten days prior to the surgery UNLESS DIRECTED BY YOUR PHYSICIAN. These medications may “thin” your blood and cause more bleeding. You may substitute acetaminophen (Tylenol) if required. Do not drink any alcoholic beverages for 24 hours before surgery.
Shampoo your hair the night before surgery, as your wound and initial dressing may have to remain dry for 48 hours thereafter. The length of the procedure varies depending on the size and location of the skin cancer and the type of reconstruction to be done. You should plan on spending most of the day in our office. We ask that you limit the number of people accompanying you to one other because of the limited space in our waiting room. There is plenty of time spent waiting for the lab work, so bring a book or handiwork to keep busy, and lunch or a snack.
The Day of Surgery
Appointments for surgery are scheduled throughout the day. It is a good idea to wear loose fitting clothing and avoid “pullover” clothing. Also, if the operative site is on the face, please do not wear make-up. We will obtain your written consent for the procedure, photographs will be taken, and your blood pressure will be recorded. If you have any additional questions, please feel free to ask them at this time.
The area surrounding the skin cancer will be cleansed with an anti-bacterial soap. The doctor will then anesthetize (numb) the area of skin containing the cancer by a small local injection. This injection will probably be similar to the one you received for your biopsy. We will be as gentle as we can when administering this. It usually takes 15 minutes to anesthetize the involved area and remove the tissue. After the tissue has been removed, it will be processed in our office laboratory. Depending on the amount of tissue removed, processing usually takes an additional 45 minutes. Your wound will be bandaged, and you will move to the waiting room while the tissue is processed and examined by your physician. If the microscopic examination of the removed tissue reveals the presence of an additional tumor, we will go back and remove more tissue. The Mohs technique allows us to precisely map out where the roots of the cancer remain. Most skin cancers are removed in 1-3 surgical stages.
After 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 letting the would heal by itself, closing the wound in a side to side fashion with stitches, closing the wound with a skin graft or a flap. In most cases, the best method is determined on an individual basis after the final defect is known. Sometimes other surgical specialists may be utilized for their unique skills if the tumor turns out to be larger than initially anticipated. We individualize your treatment to achieve the best results.
When the reconstruction is completed by the other surgical specialists, that reconstruction may take place on the same day or on a subsequent day. There is no harm in delaying the reconstruction for several days. If the reconstruction is to be extensive, that portion of the operation may require hospitalization. This is the exception rather than the rule.
Your surgical wound will likely require care during the weeks following surgery. Detailed written instructions will be provided. You should plan on wearing a bandage and avoiding strenuous physical activity for a week. Most of our patients report minimal pain which responds readily to Tylenol. You may experience a sensation of tightness across the area of surgery. Skin cancers frequently involve nerves and months pass before your skin sensation returns to normal. In rare instances, the numbness may be permanent. You may also experience itching after your wound has healed. Complete healing of the surgical scar takes place over 12-18 months. Especially during the first few months, the site may feel “thick”, swollen, or lumpy, and there may be some redness. Gentle massage of the area (starting about 1 month after the surgery) will speed the healing process.
An indefinite follow-up period of observation is necessary after the wound has healed. You will be asked to return in six weeks, six months and one year following the procedure. Studies have also shown that once you develop a skin cancer, there is a strong possibility of developing other skin cancers in the future. Should you notice any suspicious areas, it is best to check with your physician for a complete evaluation. You will be reminded to return to your dermatologist on a frequent basis for continued surveillance of your skin.
Risks of Surgery
Because each patient is unique, it is impossible to discuss all the possible complications and risks in this format. The usual risks are discussed below. Your physician will discuss any additional problems associated with your particular case. Please understand that these occurrences are the exception and not the rule.
• The defect created by the removal of the skin cancer may be larger than anticipated. There is no way to predict prior to surgery the exact size of the final defect.
• There will be a scar at the site of the removal. We will make every effort to obtain optimal cosmetic results, but our primary goal is to remove the entire tumor. Again, Mohs surgery will leave you with the smallest wound thus creating the best opportunity for optimal cosmetic results.
• There may be poor wound healing. At times, despite our best efforts, for various reasons (such as bleeding, poor physical condition, smoking, diabetes, or other diseases), healing is slow or the wound may reopen. Flaps and grafts utilized to repair the defect may at times fail. Under these circumstances, the wound will usually be left to heal on its own.
• There may be a loss of motor (muscle) or sensory (feeling) nerve function. Rarely, the tumor invades nerve fibers. When this is the case, the nerves must be removed along with the tumor. Prior to your surgery, the doctor will discuss with you any major nerves which might be near your tumor.
• The tumor may involve an important structure. Many are near or on vital structures such as the eyelids, nose or lips. If the tumor involves these structures, portions of them may have to be removed with resulting cosmetic or functional deformities. Furthermore, repairing the resulting defect may involve some of these structures.
• Rarely, wounds become infected and require antibiotic treatment. If you are at particular risk for infections, you may be given an antibiotic prior to surgery.
• There may be excessive bleeding from the wound. Such bleeding can usually be controlled during surgery. There may also be bleeding after surgery. We have never had a significant amount of blood loss, but bleeding into a sutured graft or flap may inhibit good wound healing.
• There may be an adverse reaction to medications used. We will carefully screen you for any history of problems with medications: however, new reactions to medications may occur.
•There is a small chance that your tumor may regrow after surgery. Previously treated tumors and large, longstanding tumors have the greatest chance for recurrence.
• DO advise us as soon as possible if you must cancel or change your appointment.
• DO get a good night’s sleep prior to surgery.
• DO take your usual medications on schedule unless instructed otherwise.
• DO eat a big breakfast.
• DO dress comfortably.
• DO ask any questions you might have.
• DO let our staff know if you take Coumadin, antibiotics before dental work or blood pressure medications.
• DO NOT take aspirin or any aspirin containing products for ten days prior to the surgery, UNLESS DIRECTED BY YOUR PHYSICIAN. Please read the label on all the over the counter medicines.
• DO NOT consume alcohol 24 hours prior to or 48 hours after surgery.
• DO NOT smoke 24 hours prior to or 2 weeks after surgery—it impedes wound healing and decreases survival of flaps and grafts.
Pre Operative Patient Checklist
• I understand the nature of the Mohs procedure and have received a detailed information booklet, which I will read and ask any questions prior to surgery.
• I understand the risks of Mohs Surgery including, but not limited to: Risk of infection, scar/hypertrophic scarring, bleeding, graft or flap necrosis, sensory dysesthesias at surgery site, the risk of nerve injury, need for scar revision, pain at the surgery site, asymmetry, delayed healing, tumor recurrence.
• I give permission for photographs to be taken for documentation purposes.
• I understand that I should take all of my usual medications (unless specifically stated not to) the day of the Mohs procedure and the day of the repair. I will eat breakfast prior to my Mohs procedure.
• I understand that if I drink alcohol 2 days prior to, and/or 48 hours after surgery, I run an increased risk of bleeding from the surgery.
• I understand that if I smoke prior to, and after the surgery, I have a MUCH increased risk of graft or flap necrosis.
• I understand that aspirin increases the risk for bleeding during surgery, I understand that if my cardiologist has me on aspirin, Coumadin or other “blood thinners”, I need his/her permission to stop this prior to surgery.
• I have received a copy of these pre-operative instructions along with a detailed explanation of Mohs Surgery and potential complications.
• If your surgery involves your face and you are a contact lens wearer, please wear your eyeglasses on the day of surgery.
Christopher, Conti, M.D.
Christopher M Conti, M.D. is a board certified Dermatologist, a Mohs and Reconstructive fellowship trained surgeon, and skin cancer specialist. Dr. Conti is originally from upstate New York and received his medical degree at New York Medical College in Valhalla, New York. He then completed two years of internal medicine at SUNY Health Sciences Center in Syracuse, New York, followed by a one year fellowship in Photodynamic Therapy and Cutaneous Oncology at Roswell Park Cancer Institute in Buffalo, New York. Dr. Conti then completed a three year Dermatology residency at SUNY Health Sciences Center at Buffalo, where he also served as chief resident, and subsequently received his board certification in Dermatology. Finally, he completed a MohsCollege approved fellowship in Mohs Micrographic Surgery and Reconstruction under the direction of Dr. Anthony Benedetto in Philadelphia, Pennsylvania.
Schedule an Appointment
For more information about Mohs Surgery or to make an appointment
• Call 302-633-7550 ext 439 or 259
Please visit the following websites to learn more about skin cancer and Mohs Surgery:
• American College of Mohs Micrographic Surgery
• American Academy of Dermatology
• Skin Cancer Foundation
• Skin Cancer Net
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