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Mohs Surgery FAQ's and Links
Mohs Surgery
Microscopically Controlled Excision (MMS) of Skin Cancer
"Medical authorities estimate that one out of every seven Americans will develop some form of skin cancer . . . 90% of those cancers will appear on the face . . . " The Skin Cancer Foundation, 1980.
Approximately 40 years ago, Dr. Fredrick Mohs, professor of surgery at the University of Wisconsin, developed a technique known as chemosurgery to treat skin cancers. This procedure provides patients with an excellent chance for cure. However, since the method is time-consuming and requires highly specialized training and personnel, only a few medical centers and fewer private offices in the United States are equipped to offer such treatment. The large number of patients who have been cured clearly demonstrates that Mohs surgery is a highly successful treatment for skin cancer.
This list of questions and answers attempts to answer some of the questions you may have as a patient concerning the procedure for treating skin cancer. Should you have any further questions, please do noy hesitate to contact us at any time.
What is Skin Cancer?
Cancer is a tissue which grows at an uncontrollable and unpredictable rate. There are three main forms of skin cancer: basal-cell carcinoma, squamous-cell carcinoma, and malignant melanoma. These names refer to the cells of the skin giving origin to the skin cancer.
How Does Skin Cancer Start and How Does it Grow?
Skin cancer begins in the uppermost layer of the skin and grows inward, forms roots, and spreads horizontaly along the surface of the skin. Unfortunately, these extensions cannot be directly visualized. Therefore, what is apparent to the naked eye actually may be onlt the 'tip of the iceberg'.
Is it Dangerous?
The most common types of skin cancer are basal-cell carcinoma and squamous-cell carcinoma. Both types enlarge locally from their points of origin and usually do NOT spread (metastasize) to different parts of the body. If not completely removed, both types will frequently invade and destroy structures in their paths of growth. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are therefore easily cured.
Malignant melanoma, on the other hand, may be life-threatening if not treated early. It usually appears as a brownish-black spot or bump on the skin which usually enlarges and sometimes bleeds. Occasionally, melanomas originate in moles which have been present for many years.
What Causes Skin Cancer?
The causes of skin cancer like other forms of cancer, are not completely known. Excessive sunlight exposure is the single, most important factor in the development of these skin cancers, which most frequently on the face and arms (the body parts with the highest sun exposure). Fair-skinned people develop skin cancer more frequently than dark-skinned people. Skin cancer, unlike cancer of other organs, is rare in blacks and more common in the southern United States. Skin cancer also tends to be hereditary and occurs frequently in certain ethnic groups, especially ones with fair complexions such as northern Italians and Celtics (especially Irish). Other possible factors for skin cancer development include, x-ray, trauma, and certain chemicals.
How May Skin Cancer be Treated?
There are several methods of treating skin cancer, all highly successful in the majority of patients. These methods include excision (surgical removal) and suturing (sewing); curretage and electrodesiccation (scraping and burning with an electric needle); radiotherapy (x-rays); cryosurgery (freezing); topical chemotherapy (chemical destruction); Mohs surgery (micrographic surgery).
What is 'Mohs' Surgery?
Although originally called 'chemosurgery', the technique has evolved over the years and now involves the use of frozen sections and as well as mapping of tumor extent. It is currently refered to as 'Mohs micrographic surgery' (MMS).
How is Mohs Surgery Preformed?
There are three seperate steps to the technique of Mohs surgery. 1) Curretage of the visible part of the skin cancer; 2) surgical removal or excision to a certain depth of that tissue; 3) surgical specimens are frozen, stained with specific chemicals, and examined under the microscope. If more cancer is found, the procedure is repeated, but only in the areas of the remaining cancer.
How Long Does it Take?
Total removal of skin cancer, which may involve several surgical sessions of a few hours duration, is usually completed in one day. After a surgery, a descision is usually made as to the best way to manage the wound created by the surgery.
How Effective is Mohs Surgery in the Treatment of Skin Cancer?
By the technique of Mohs surgery, the percentage of success is very high, often 97% to 99%, even if other forms of treatment have failed. Therefore, with this technique, an excellent chance of cure is achieved.
What Are the Advantages of Mohs Surgery?
Using the microscopic examination, the Mohs surgeon can pinpoint areas involving cancer and selectively remove tissues only from those areas. In this way, the cancer is traced out to its roots. This results in the removal od as little normal tissue as possible and have the highest chance of cure. Other forms of therapy frequently have only a 50% to 70% chance of success in curing skin cancers that have had previously unsuccessful treatment, whereas the chances with Mohs surgery are much better.
Will the Surgery Leave a Scar?
Yes. Any form of therapy will leave a scar. However, Mohs surgery tends to show less of a scar as most other treatments do.
What Happens at the Preoperative (Consultative) Visit?
The preoperative visit gives the physician an oppurtunity to examine your skin cancer, take a pertinent history, and determine whether the technique of Mohs surgery is the most suitable way for treating youe skin cancer. Also, it gives you the oppurtunity to learn about the procedure. Every skin cancer is different; because of the high demand for Mohs surgery, careful scheduling is necessary. A suitable date for the surgery that is mutually acceptable will be arranged. When a patient has been refered for Mohs surgery, usually the biopsy (the removal of a piece of tissue) has already been preformed; we have the pathologic report stating the type of skin cancer present. If we do not have that information, we usually preform the biopsy at the initial visit. This is a simple procedure which only takes a few minutes. Since all skin cancers are not alike, we need to know exactly what type you have before we proceed. All patients are photographed before any treatment (usually at the initial visit), as well as immediately after surgery and healing. These photographs become part of your medical record and may be used for teaching purposes.
Will I Need to be Hospitalized?
Probably not. Whenever possible, the surgery is preformed on an outpatient procedure; occasionally we require that the patient stay in the hospital. We will inform you if we feel it is best for you to be hospitalized.
How Should I Prepare Myself for Mohs Surgery?
Try to get a good night's sleep and eat a light breakfast. If you are taking any medication, take it as usual unless we direct otherwise. It is a goos idea to bring a magazine, book, or other item that will keep you occupied; the procedure may take a full day and much time will be spent in the waiting room.
Should Someone Come With Me the Day of the Surgery?
Yes, it may be pleasant to have company while you are sitting in the waiting room. It is also recommended to have someone available to drive you home.
Does it Hurt?
To reduce anxiety, most patients are premedicated with Valium. The physician will use a local anesthetic, usually Xylocaine, to numb the skun around the skin cancer. Be sure to inform the surgeon if you experience anything more than slight discomfort.
How Long Does the Surgery Take?
Appointments for surgery are usually scheduled early in the day, allowing the physician to continue on into the entire day if necessary. The first step is for the surgeon to surgically remove a thin layer of skin in volved with the cancer. After which, the nurse will dress your wound and send the tissue to the labratory for microscopic examination. That process takes about an hour or so, but can take somewhat longer. If the slide examination that the tissue still has cancerous cell, the process will be repeated until the tissue has very little to no cencerous cells left inside it. On average, it will take two to three surgical sessions to finish the surgery. By that time, it will be around midday. If you must stay longer, you will be able to have a light lunch but NO alcoholic beverages. It is seldom necessary for the patient to return again the next day for more surgery.
Will I Have Pain After the Surgery?
Most patients do not complain of pain. If you are uncomfortable, we recommend taking two tablets of Tylenol or Datril every four hours. Avoid asprin-containing compounds such as Anacin, Bufferin, Motrin, Nupin, etc., as they may produce bleeding.
What About Bleeding After the Surgery?
Rarely does bleeding occur after surgery. If this should happen, lie down and place steady, firm pressure over the bandage as close as possible to the area that is oozing blood. Apply the pressure continuously for 20 minutes (timed). Do not lift the bandage to check on the bleeding. If it persists after 20 minutes of pressure, notify the surgeon's office or go to the nearest hospital emergency room. Application of ice for ten minutes every hour for 6 hours helps to reduce the bleeding.
What Are Some Other Possible Complications?
All wounds develop a small, surrounding halo of redness which disapperas gradually. Severe itching with extensive redness may indicate a reaction to adhesive tape. You should call the surgeon's office if this developes. Swelling is common after Mohs surgery, particularly when it was preformed around the eyes. All wounds show a moderate amount of swelling, which is usually not a problem.
What is the Next Step After Mohs Surgery Has Been Completed?
When we have determined that the skin cancer has been completely removed, a descision is made on what to do about the wound created by the surgery. Usually, there are three choices. 1) Close the wound with stitches; 2) let the wound heal by itself; 3) cover the wound with a skin graft or flap. The surgeon will recommend which of these choices will be best for your individual case.
What Happens if the Wound Can be Closed Immediately With Stitches or if a Skin Graft is Used?
If the surgeon closes the wound with sutures (stitches) or place a graft, keep the wound clean and dry until the next visit. If a foul-smelling fluid oozes from the wound, call the surgeon's office immediately. This may mean that the wound has become infected and an antibiotic may be necessary.
If the Wound is Allowed to Heal by Itself, What is the Procudure?
If the wound is allowed to heal by itself (granulate in), it usually does so in four to eight months. The dressing may be changed every day until the healing is complete. All wounds normally drain and dressings are changed daily to rid the wound of such drainage. The surgeon's nurses will instruct you on how to change the dressing.
What Happens After the Wound has Healed?
You may experience a sensation of tightness or drawing as the wound heals, but this is normal. After several months, you will feel this less and less. Frequently, tumors involve nerves, so it may take a year or two before feeling returns to normal. Sometimes, the area will numb permanently. Only time will tell. The new skin that grows over the wound contains many more blood vellels than the skin before it. This results in a red scar and the area may be sensitive to changes in temperature. This sensitivity lessens with time and the redness gradually fades. However, if you are experiencing a lot of discomfort, try to avoid extremes of temperature. Patients frequently experience itching after their wounds have healed because the new skin does not have as many oil glands as it previously did. Plain petroleum jelly will help relieve the itcing.
Once the Wound has Healed, How Often Must I Return for a Follow-Up?
A follow-up period of observation for at least five years in essential. After the wound has healed, the surgeon's practice is to have patients return to their referring physicians for yearly visits. Studies have shown that once you develop skin cancer, there is a possibility that you will develop others in the years ahead. We recommend that you be seen at least once a year for the rest of your life by your dermatologist so that he/she may determine whether or not you have developed more. Also, should you yourself notice any suspicious areas on your skin, it is best to check with your referring physician to see if a biopsy is indicated. Should there be a reccurnce of the skin cancer after the Mohs surgery, it may be dectected at once and treated. Experience has shown that if there is a reccurance, it will usually be within the first year following the surgery.
My Skin Cancer has Been Treated Several Times. Will I Ever be Cured?
A frequent reason for being sent to the surgeon for Mohs surgery is that other forms of treatment have failed. This does not mean that the methods used to treat you in the past were not effective enough to destroy some of the cancer cells. Because Mohs surgery uses complete, systematic, microscopic control to search out the roots of the skin cancer, it cures almost all patients - even those whom skin cancer has persisted in spite of several other treatments.
Later on, Must I Avoid the Sun?
No, not entirely. We do not think that sunshine will be harmful to you as long as you provide yourself with adequate protection, avoid burning, and use discretion. As mentioned earlier, sunshine is probably the main contributor to the development of skin cancer; patients whi have developed one skin cancer will often develop more at a later time. Therefore, in the future, when you go in the sun, we recommend that you liberally apply a sunscreen with a sun-protection factor of 15 to all exposed areas, including the tops of your ears. It is best to apply the sunscreen about 15 minutes before going outdoors. Be sure to reapply it liberally after swimming or excercising, since most sunscreens wash off with water of perspiration. Avoid going outdoors between 10:00 in the morning and 2:00 in the afternoon, when the rays from the sun can do the most damage. In addition to using the sunscreen, you may wish to wear a broad-brimmed hat and use clothing to further protect youself from the sun. Yes, you can enjoy a normal lifestyle - IF you take precautions. Remember, an ounce of prevention is worth a pound of cure!
Here Are Some Helpful Links About Mohs Surgery!
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