MOHS MICROGRAPHIC SURGERY
Our goal at the Cheyenne Skin Clinic and Center for Dermatologic Surgery is to provide you with the highest quality care for the treatment of your skin cancer. One of the treatment methods we offer is Mohs micrographic surgery. This information is designed to explain the procedure in detail and answer questions commonly asked by patients.
What is Mohs Micrographic Surgery?
A skin cancer that has been biopsied often resembles a “tip of an iceberg” with more tumor cells growing downward and outward into the skin, like roots of a tree. These “roots” are not visible with the naked eye, but can be seen under a microscope. Mohs micrographic surgery is a treatment for skin cancer in which cancerous cells are removed in stages, one tissue layer at a time. Once a tissue layer is removed, its edges are marked with specially colored dyes, and a map of the specimen is created. The tissue is then processed onto microscope slides by a trained Mohs surgery histotechnician in our on-site laboratory. These slides are carefully examined under the microscope by our Mohs surgeon so that any microscopic roots of the cancer can be precisely identified and mapped. When cancer cells are seen, an additional tissue layer is removed only in areas where the cancer cells are still present, leaving normal skin intact. This allows the Mohs surgeon to save as much normal healthy skin as possible
The term “Mohs” refers to Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, who developed this surgical technique in the early 1940s. The technique has undergone many refinements and has come to be known as “Mohs surgery” in honor of Dr. Mohs.
What are the Advantages of Mohs Micrographic Surgery?
Mohs micrographic surgery is safe, reliable, and has a significantly higher cure rate than any other available treatment, even when dealing with difficult cases and those that have failed other forms of treatment. In addition, Mohs surgery is a “tissue-sparing” technique, which allows for selective removal of cancerous tissue while preserving as much normal skin as possible. Mohs surgery is done as a same-day outpatient surgical procedure that eliminates the need for general anesthesia and hospital fees. Mohs surgery is performed by a physician who is both the surgeon and the pathologist and has received specialized training in this technique.
With standard skin cancer excision, only a portion of the removed tissue is sampled and examined microscopically by a pathologist to determine whether the cancer is completely removed. Mohs micrographic surgery allows for examination of the entire underside and edges of the tissue which results in a higher cure rate while minimizing the removal of normal tissue.
Because Mohs surgery is a highly specialized technique, not all skin cancers require this treatment. Skin cancers that have “come back” after previous treatment, a tumor with microscopic features suggesting it may be aggressive or have extensive roots, and a skin cancer on the nose, eyelids, ears, fingers or other areas in which sparing of normal tissue is essential.
About Our Staff
Our Mohs Micrographic Surgery Center is staffed by a team that includes a Mohs micrographic surgeon, Dr. Julie Neville; surgical technicians who will assist in surgery, respond to your concerns, help answer questions, and instruct you in wound care following your surgery; and laboratory histotechnicians who work in our on-site laboratory preparing the tissue slides which are examined by Dr. Neville under a microscope. Our front office staff is available to answer any questions relating to appointment scheduling, insurance forms, and payments.
How Do I Prepare for the Day of Surgery?
- Please plan to spend at least six hours at the office. Since most of the time will be spent waiting while we study the tissue, it is helpful to have a book to read. You may also want to bring one other person to stay with you during the wait.
- If you are on doctor-prescribed aspirin , Coumadin or Plavix, please continue to take it.
- Unless doctor-prescribed, do not take aspirin or aspirin-containing medications (Alka-Seltzer, Anacin, Excedrin, Aleve, Bufferin, Emprin Compound, Ecotin and many “cold pills”) or Motrin, Advil, Nuprin, and ibuprofen for two weeks before and five days after surgery. Tylenol or acetaminophen are acceptable to take during this period.
- Please do not take any vitamin E, gingko, ginsing, garlic, fish oil, herbal supplements, or anti-inflammatory pain medications (such as ibuprofen, Advil, Motrin, Alleve, Nuprin and others) for two weeks prior to your surgery. These also cause thinning of the blood, which can result in increased bleeding during your surgery. These medications and supplements may be resumed 48 hours after your surgery.
- Smoking causes changes in the bloodstream that interfere with the process of normal wound healing; this can negatively affect the cosmetic outcome of your surgery and limit our options for repairing your wound. Please make every attempt to quit smoking for at least 2 days before and two weeks after surgery.
- On the morning of surgery, eat a normal breakfast. Take any medication that you normally take.
- If you have been given an antibiotic to take before surgery, be sure to take it as directed one hour before surgery. Failure to do so may result in cancellation of the surgery. If you do not have a prescription, please call us as soon as possible before your surgery date so that we may call in a prescription to your pharmacy
- Wear a button down shirt or blouse if the surgery is on the face or head. For surgery on legs, wear pants with loose fitting legs or a skirt if possible. Wear loose comfortable shoes for surgery on the feet.
- Do not apply cosmetics if the surgery is going to be performed on your face.
- It is helpful to have Extra Strength Tylenol (or acetaminophen) at home prior to the date of surgery as well as bandaging supplies such as non-stick bandages (Telfa) and paper tape.
- If you have taken any anti-anxiety medications before surgery, you must have someone available to drive you to and from surgery.
What happens on the day of surgery?
You should plan on spending most of the day with us. The area around the site of your skin cancer will be anesthetized (numbed) with a local anesthetic. Once the area is numbed, a thin layer of tissue will be removed and any bleeding will be controlled. The tissue will be mapped, color-coded, and sent to our on-site Mohs laboratory to be processed onto microscope slides. A bandage will be placed over the wound, and you will return to the Mohs surgery waiting area or general dermatology waiting area.
On average, it takes 1 to 1½ hours for the slides to be prepared and studied. Occasionally, tissue requires special attention and may take longer for processing or examination. If there is cancer still present, an additional layer, or stage, is taken. Most Mohs surgery cases are completed in two or three stages. Therefore, Mohs surgery is generally completed in one day. Occasionally, however, a tumor may be extensive enough to necessitate continuing surgery a second day. Once the tumor has been cleared, surgical repair of the skin will require additional time.
What Happens After the Tumor Has Been Removed?
After the skin cancer has been completely removed, you will have a surgical wound. Dr. Neville will discuss your options with you and make recommendations. At this point, optimizing the wound healing and final cosmetic result of your surgery becomes our highest priority. The wound can be treated in one of several ways:
- Healing by "secondary intention" (see below)
- Closing the wound in a straight line with stitches.
- Closing the wound with a skin flap. A skin flap uses nearby skin to help fill in the wound. Flaps can be used when simpler repair options (second intention healing or a linear wound closure) will not adequately heal the wound with a good result.
- Closing the wound with a skin graft. A skin graft is skin borrowed from a different area to fill in the wound. Skin grafts are used when simpler repair options will not adequately heal the wound with a good result.
- In special cases, a consultation with one of several reconstructive surgeons may be necessary.
What is “Healing By Secondary Intention?”
Occasionally, a wound is allowed to heal in by itself without stitches. This is referred to as “healing by secondary intention.” In certain areas of the body, nature will heal a wound as nicely as a surgical procedure involving stitches. In other areas of the body, healing by secondary intention is avoided since unacceptable scars can result. Use of this option for healing will depend on the size and location of your wound following surgery.
If a wound is allowed to heal by itself, often a porcine (temporary) graft is placed on the area to help stimulate wound healing. This graft will fall off on its own in 1 to 2 weeks. The area needs to be cleaned daily and kept moist with Vaseline and a bandage. The surgical staff will teach you how to change the dressing and will give you printed instructions. If a wound is allowed to heal by secondary intention, it usually heals in four to eight weeks, depending on the size of the wound and on how quickly an individual tends to heal.
What Happens if the Wound is Closed with Stitches?
Wounds are often closed with stitches. This speeds healing and can optimize the cosmetic result. For example, a scar can be camouflaged into a facial line or wrinkle line. The resulting line of stitches tends to be longer than the length of the original wound. This is done to avoid unnatural puckering and dimpling of the skin that would occur if the incision were not lengthened.
The surgical staff will teach you how to change the dressings daily and provide you with printed instructions. You will be given specific activity restrictions. The stitches will need to be removed in 5 to 14 days, depending on the location.
What Can I Expect After the Surgery?
Following your surgery, we will discuss postoperative care with you, and you will be given detailed written instructions on the care of your wound. Swelling and slight bruising are common following Mohs surgery. A “black eye” is common with surgery around the eye, or on the forehead. These symptoms usually subside within 5 to 7 days after surgery and may be reduced by sleeping with your head slightly elevated and by using an ice pack for short periods of time during the first 24 hours.
Restrictions: Depending on the size and location of the wound, Dr. Neville may recommend restrictions in your physical activity following the surgery. Details will be discussed with you after the surgery is complete. Depending on the extent of your surgery and the requirements of your occupation, you may wish to take off one or more days from work following your surgery. Many patients are able to return to work the day after surgery. If the surgery is on the lips or mouth, we recommend eating soft foods while the stitches are in.
Pain: In most cases, patients experience very little discomfort after Mohs surgery. We request that you do not take aspirin or ibuprofen-containing drugs for pain control. Tylenol (acetominophin) does not contribute to increased bleeding and can be used for discomfort. Additional pain medication may be prescribed.
Bleeding: Mild bleeding or oozing at the surgical site is fairly common following Mohs micrographic surgery. When it occurs, bleeding is typically a slow ooze at the wound edges and is best controlled through the use of pressure. If you experience bleeding, you should move to a seated position and apply constant pressure on a gauze pad over the bleeding point for 20 minutes (timed); do not lift up or release the pressure at all during that period of time. If bleeding persists after continued pressure for 20 minutes, remain seated and repeat the pressure for another 20 minutes. If this fails, call our office or phone numbers provided on your postoperative instructions.
Infection: Infection following Mohs surgery is uncommon. A small amount of drainage on the bandage is to be expected. In addition, a small red area may develop around your wound. This is normal and does not indicate infection. However, if the redness worsens and the wound becomes tender, warm or begins to drain pus, you should notify our office immediately.
Allergic reaction: Itching and redness around the wound can indicate allergy to bandage materials such as tape adhesive or antibiotic ointment. Following your surgery, you will be given specific instructions for wound care to minimize this risk. If you experience itching or a rash on the rest of your body after you have started an oral antibiotic or pain medication prescribed by Dr. Neville, this may indicate a medication allergy. If this occurs, please discontinue the medication and immediately call our office or Dr. Neville.
Numbness: It is common for the area around the surgery site to feel numb to the touch. This area of numbness may persist for several months before returning to normal or near normal. In rare instances, the area stays numb permanently. In addition, some areas may be sensitive to temperature changes (such as cold air) following surgery. This sensitivity improves with time.
Itching: Patients frequently experience itching after their wounds have healed. This occurs because the new skin that covers the area does not have as many oil glands as previously existed. Plain petroleum jelly will help relieve the itching.
Will There Be a Scar?
Yes. Any treatment for skin cancer will leave a scar. Mohs surgery preserves as much normal skin as possible to maximize options for repairing the area where the skin cancer had been. Once Dr. Neville has removed your skin cancer completely, optimizing the final cosmetic result of your surgery becomes our highest priority. In general, a postsurgical scar improves with time and can take up to one year or more to fully mature. As your surgical site heals, new blood vessels can appear to support the healing changes occurring underneath the skin. This can result in a red appearance of the scar. This change is temporary and will improve with time. In addition, the normal healing process involves a period of skin contraction, which often peaks at 4-6 weeks after the surgery. This may appear as a bumpiness or hardening of the scar. On the face, this change is nearly always temporary and the scar will soften and improve with time. If you have a history of abnormal scarring, such as hypertrophic scars or keloids, or if there are problems with the healing of your scar, injections or other treatments may be used to optimize the cosmetic result. Dr. Neville is available for you throughout the healing process to discuss any concerns that arise.
How Often Will I Return For a Follow-Up Visit?
If you have sutures, you will need to return for suture removal. You may also need to return within one to three months after the surgery to ensure that the healing process is progressing smoothly. If you have questions or concerns, please call our office or schedule a return appointment at any time.
Can My Skin Cancer Come Back?
The goal of Mohs micrographic surgery is to remove your skin cancer while preserving your normal healthy surrounding skin. The cure rate for Mohs surgery is very high, even for the most difficult tumors. The cure rate is approximately 99 percent for new skin cancers and 95 percent for recurrent skin cancers (those which have been treated in the past and have come back.) However, no one can guarantee a 100 percent cure rate with any treatment method.
Will I Develop More Skin Cancers?
Studies have shown that once you develop a skin cancer, there is an increased risk of developing others in the years ahead. For this reason, it is important for you to continue seeing your dermatologist at regularly scheduled intervals and to schedule an appointment if you are concerned about new or changing growths on your skin. The best way to minimize your risk of developing more skin cancers is to protect your skin from the sun’s damaging rays.
If you have additional questions or concerns regarding your upcoming surgery, please contact our office at (307) 635-0226 and ask to speak with one of the dermatology nurses.