Mohs Skin Cancer Surgery

Mohs Micrographic Surgery

Mohs surgery, also called Mohs micrographic surgery, is a specialized technique for removing skin cancer. Named after its inventor, Dr. Frederic Mohs, Mohs surgery is the treatment of choice for many skin cancers. It offers the following advantages:

• Highest cure rate. Because all surgical margins are examined microscopically in the office, this procedure has the highest cure rate of all skin cancer treatments.
• Best cosmetic result. Because there is no need to take a margin of healthy skin in Mohs surgery, the size of the wound left after tumor removal is minimized. Keeping the defect small optimizes the surgical repair, and produces a superior cosmetic result.

Mohs surgery is an outpatient procedure that is performed under local anesthesia; therefore the risks associated with prolonged general anesthesia is avoided. Before the surgery begins, a small needle is used to place the numbing medicine (lidocaine) in the area surrounding the skin cancer. After this first step, the remainder of the procedure is relatively pain free. The surgeon first removes the obvious skin cancer that can be seen with the unaided eye. Then a very thin saucer-shaped layer of normal appearing skin is removed taking special care to map the tissue so that the surgeon is able to determine the corresponding margins on the patient. The tissue is then processed by the laboratory located in our office – a process that takes about an hour. After processing, the surgeon uses a microscope to trace the roots of the skin cancer to see if the entire tumor has been removed. If the margins are clear, and the tumor has been completely removed, then the surgeon will repair the wound that was created by tumor removal. The repair usually involves sutures.

If the margins are not clear, meaning that some of the tumor was left behind, then the surgeon will go back and remove the edges only in the area where the roots were left behind. This will likewise be processed and examined with a microscope. If tumor removal is complete, then sutures will be used to repair the defect, if not, then another layer of skin will be taken. This process is repeated as many times as necessary until the entire tumor is removed.

Because the number of stages involved with each case is unpredictable, it is impossible to know how long the surgery will take. For this reason, it is important for patients to plan on spending the entire day with us. Bring a good book and whatever else will help keep you comfortable while you are with us.

Frequently Asked Questions

What does "Mohs" stand for?
Dr. Frederic Mohs developed this technique about 60 years ago. The procedure has been modified and refined over the years. Practitioners of the technique have kept Dr. Mohs’ name in respect for his contribution. Mohs surgery has other names including Mohs chemosurgery, Mohs microscopically controlled surgery, and Mohs micrographic surgery.

Are there different types of skin cancer?
Yes. The most common type of skin cancer is basal cell carcinoma. Often these skin cancers are very subtle, and appear like a small pimple that will not heal and often bleed. The second most common skin cancer is squamous cell carcinoma. This type is usually appears as a thickened scaly plaque or nodule. The third most common type is melanoma, which behaves differently that either basal cell carcinoma or squamous cell carcinoma. Melanoma most commonly appears as an abnormal mole.

Are skin cancers life-threatening?
Fortunately, the two most common types of skin cancer, basal cell carcinoma and squamous cell carcinoma, are rarely life threatening. As a general rule, basal cell carcinoma does not spread to the glands or other parts of the body. Compared to basal cell carcinoma, squamous cell carcinoma has an increased risk to spread to other parts of the body. Fortunately distant spread is uncommon when the cancer is treated early. However, both types of tumors will continue to grow locally and destroy normal tissue. The third most common type of skin cancer, melanoma, can be life threatening if treated late. Basal cell skin cancers and squamous cell cancers never “turn into” melanoma.

How large of a scar will I have from the surgery?
The size of the scar depends on the size of the tumor. It is often difficult to predict the size of the tumor prior to surgery.

Will I have stitches following the surgery?
Most patients will have stitches. There are three main ways your surgical wound may be handled:
1. Direct closure of wound with stitches. This is the most common method.
2. Skin graft or flap: In some instances, it is necessary to remove skin from behind the ear or some other site and graft it over the wound. Other times skin that is located near the wound is moved in to fill the defect left from surgery – this is a skin flap.
3. Let wound heal in by itself. The body has an excellent capacity to heal open wounds. This healing period is approximately three to six weeks depending on the size of the wound. It requires regular wound care.

In addition to wound size and location, the surgeon considers other factors in determining how your wound will be handled. This will be fully discussed with you on the day of surgery.

Will I be put to sleep for the surgery?
No. The surgery is well tolerated with local anesthesia. Because the surgery may be time-consuming, the risk of prolonged general anesthesia is thus avoided.

How long will the surgery last?
The length of surgery depends on the extent of the tumor. Often surgery lasts half a day or longer. Much of the time is spent waiting for tissue to be processed. Bring reading materials, needlework, etc., with you to help pass the time. Also, you may want to bring a snack or lunch with you on the day of surgery.

What if I live far away from the Kingsport area?
If your travel distance is great you might want to spend the night before surgery in the Kingsport area. There are a few moderately priced hotels nearby. A list of these is available upon request.

Should I bring someone with me?
It is often helpful to bring someone with you on the day of surgery. Depending on the size and location of your tumor, driving is sometimes a challenge after surgery, and having a driver with you is a good idea. Additionally, if someone other than the patient will be performing post-op wound care, the nurse can give this person direct instructions, demonstrate wound care, and answer any questions about the surgery.

What should I wear?
You should wear comfortable clothing. You may want to bring a sweater, as our office is kept cool for the laboratory equipment that is needed for this procedure.

Should I eat breakfast before surgery?
Yes. Breakfast is recommended.

Should I take my regular medications on the morning of the surgery?
Yes. Take your regular medications as they have been prescribed.

Are there any medications I should avoid prior to surgery?
If you take aspirin on a regular basis at the direction of your physician, you SHOULD CONTINUE to take it as prescribed. If you have decided yourself to take aspirin, NOT at the recommendation of a physician, it may be beneficial to stop your aspirin 10 days prior to surgery. If you are on any other blood thinners (coumadin or Warfarin, Plavix, Ticlid, heparin, etc) please continue taking it as prescribed.

Will my activity be limited after surgery?
Yes. Physical activity, including sports, will be limited for the first week following surgery. If your work requires significant physical exertion, you may be out of work for several days after surgery. An excuse for your absence will be provided if necessary. Avoid any long trips within the first ten days following surgery in case you develop some complications. Any questions or special situations please do not hesitate to call our office.
Since I have taken antibiotics before other procedures in the past do I need to take them before Mohs surgery?
If you have taken antibiotics prior to dental or other surgical procedures, or have a history of rheumatic fever, heart murmur, artificial heart valve or artificial joint, we will prescribe one for you prior to Mohs surgery. This will help prevent infection of the heart valve or artificial joint. Pacemakers, implanted defibrillators, mitral valve prolapse and cardiac stents do not generally require antibiotics. The antibiotic used for dental work is best for bacteria found in the mouth and is not as effective for skin surgery. Please contact our office prior to surgery so that we can call or mail a prescription to you for the most appropriate antibiotic.

What are the potential complications of surgery?
Bleeding and infection are the two primary complications. Both of these are uncommon, and can be treated if they do occur. We will discuss how to recognize and deal with these problems when you come for your surgery.

Will my insurance cover the cost of surgery?
Under most circumstances your carrier will pay for surgery. If you are a member of an HMO, it may be necessary to obtain a referral or authorization from your primary physician. If you are in doubt about your particular coverage, you should check with your insurance representative prior to your appointment. If you have specific questions regarding insurance or billing matters, please contact our office at 423-246-4961.

Learn more about Mohs surgery from:
American College of Mohs Micrographic Surgery and Cutaneous Oncology
http://www.mohscollege.org/AboutMMS.html

We look forward to making sure your experience with Mohs Micrographic surgery is a positive one and appreciate the opportunity to serve you. Please do not hesitate to call with any questions or concerns.

Chad J Thomas, MD
Board Certified Dermatologist
American College of Mohs Micrographic Surgery Fellowship Trained