Mohs Micrographic Surgery
Skin cancer is the most common malignant tumor in humans. It is being seen with increasing frequency as our life span increases and as lifestyle changes maximize our exposure to the sun. There are several types of skin cancer. The most common types are basal cell carcinoma, squamous cell carcinoma, and melanoma. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), the “non-melanoma” types of skin cancer, are by far the most common. Your cumulative lifetime exposure to sunlight (ultraviolet radiation) is the single most important factor associated with the development of these skin cancers. They develop more frequently in people with fair complexions, people who live in the South, and people who work and play outdoors. Other possible contributing factors include prior radiation therapy, burns, trauma, chemicals, and immune suppression (seen with chemotherapy and chronic medical conditions). Both BCC and SCC begin in the uppermost layer of the skin and slowly enlarge, spreading both along the surface and downward. Unfortunately, these extensions cannot be directly seen. What is apparent to the naked eye on the skin surface may be only the “tip of the iceberg”. If not treated or completely removed, they will continue to grow and can invade and destroy underlying and surrounding tissues in their path. Although locally destructive, they do not tend to metastasize (break off and spread to other parts of the body). Metastasis of BCC is extremely rare and only seen in unusual circumstances. SCC is slightly more dangerous, particularly when located in certain areas and present for long periods of time.
Melanoma is a different form of skin cancer. Risk factors for this type of skin cancer is similar to the above, but also include genetics (family history of melanoma) and possibly your number of sunburns (intermittent, intense UV exposure). An increased number of moles, particularly if abnormal (dysplastic), is also a risk factor; and occasionally, melanoma may arise in a mole which has been present for many years. Melanoma arises from the melanocyte (pigment-producing cell) in the uppermost layer of the skin; but it has a tendency to grow faster and metastasize. It is life threatening if not treated early.
Mohs Micrographic Surgery
The standard methods used to treat skin cancer include surgical treatments: routine excision, electrodesiccation and curettage (scrape and burn), as well as several newer nonsurgical options: topical cancer fighting creams and photodynamic therapy (light activated chemicals applied to the skin cancer). All of the above treatments can be highly effective in experienced hands and with select tumors. Sometimes, however, these methods are unsuccessful because the skin cancer has irregular extensions (“roots”) into the surrounding normal appearing skin that are missed. Mohs micrographic surgery is a highly specialized technique for the removal of skin cancer. It was originally developed in the 1930’s by Dr. Frederick Mohs and has been refined since, gaining substantial application since the 1980’s. Originally, chemicals were applied to the skin during surgery. These chemicals are rarely used today; but occasionally the name chemosurgery is associated with the procedure. Although very precise, the major drawbacks of the procedure are that it is somewhat time consuming and requires specialized training, personnel, and equipment. Consequently, Mohs surgery is offered at only a few major medical centers and outpatient clinics in the country. There are three surgical steps to Mohs micrographic surgery:
- The surgical removal or “scraping off” of the visible portion of skin cancer (debulking).
- The surgical removal of a thin layer of tissue at the bed of the cancer. Before the tissue is examined, it is marked with colored dyes to distinguish top from bottom and right from left. A detailed map of the tissue is also made in reference to the defect on the patient. By doing this, any remaining tumor identified on microscopic examination can be pinpointed exactly on the patient. The tissue is also processed in a unique manner, which will allow examination of the entire margin of the specimen.
- The examination of this excised thin tissue layer under the microscope. By examining the entire edge and underside of the tissue, any area of residual cancer can be traced out. If more is seen, a thin layer of additional tissue is excised only from the involved area.The microscope examination is then repeated. This entire process is repeated until no tumor is found. Mohs micrographic surgery provides patients with the highest chance for cure of even complicated skin cancers with preservation of the maximal amount of normal tissue. A frequent reason for being referred for Mohs surgery is that other forms of treatment have failed. This does not mean that you are cancer prone or have a hopeless case. It merely means that methods used to treat you in the past did not destroy all of your skin cancer cells. Because Mohs micro-graphic surgery uses complete systematic microscopic control to search out the “roots” of the cancer, it cures almost all patients. Even when other treatments have failed, the cure rate can be as high as 95%; and for new skin cancers, 99%. Unfortunately, no surgeon or technique can guarantee 100% chance of cure at the present time.
This visit allows the doctor the opportunity to examine your skin cancer, obtain your medical history (please fill out the Mohs surgery pre-op questionnaire before your appointment), and determine whether the technique of Mohs micrographic surgery is the most suitable way of treating your skin cancer. It gives you an opportunity to meet the doctor beforehand, learn more about the procedure, and have any questions or concerns addressed. Every skin cancer is different; and because of the high demand for and extended nature of Mohs surgery, careful scheduling is necessary. A date for surgery that is mutually acceptable will be arranged. When patients are referred to us, usually a biopsy has already been performed and a pathology report stating the type of skin cancer is available. If this has not been done, a biopsy can be performed at the time of the initial visit. The skin cancer and surrounding skin will be photographed before treatment as well as immediately after surgery and again after healing. These photographs become part of your medical record and may be used for teaching purposes.
Getting Ready For Surgery
Unless doctor prescribed do not take any aspirin or aspirin-containing drugs (Anacin, Bufferin, etc.) for ten days prior to surgery. These medications “thin” your blood and cause more bleeding. In addition, Ibuprofen (Motrin, Advil, etc.) has a similar effect and should be avoided one week beforehand. You may substitute acetaminophen (Tylenol) if required. If you are on any other blood thinners or are unsure, please ask. We also ask that you not drink alcoholic beverages for 24 hours before surgery. Otherwise, take your usual medications on the day of surgery. Be well rested and eat a good breakfast. Shampoo your hair the night before, as your wound and initial dressing may have to remain dry for 24 hours. Althought the average length of the procedure is 2-4 hours, you should plan on spending much of the day with us. It is a good idea to bring a book or handiwork with you on the day of surgery, as much of your time will be spent waiting for the lab work. It may be relaxing to have someone with you; and bring your favorite blanket with you since our surgery rooms tend to be very cold (this will allow you to feel comfortable while the doctor loks at the skin samples). Due to limited space in our Mohs surgery waiting room, we ask that you limit the number of people accompanying you to one person (no young children, please).
Wear comfortable, loose fitting clothing; and if applicable, do not wear make-up on or around the area to be treated. When you arrive, our nurse will take you to the surgery suite and prepare the involved area of skin for surgery. If you have any additional questions, please feel free to ask them at this time. Photographs may be taken before and after the surgery. The doctor will then anesthetize (numb) the area of skin containing the cancer. This will be done with a small local injection; probably similar to the one you received when your biopsy was done. It usually takes about 15 minutes to anesthetize the involved area and remove the tissue. You will then be bandaged and directed to the waiting room. It then usually takes 30 minutes to an hour to process the tissue and examine it under the microscope. Do not leave the office without checking with the desk. If examination of the tissue removed reveals that you still have some cancer cells, the procedure will be repeated as soon as possible. Several excisions and microscopic exams (stages) may be done in one day. On rare occasions, you may have to return the following day for additional surgery. However, most patients have their entire skin cancer removed in 1-3 stages and are here for a few hours.
Once 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:
- Closing the wound in a side to side fashion with stitches,
- Letting the wound heal by itself,
- Closing the wound with a skin graft (borrowed from distant donor site) or flap (moved in from nearby or adjacent skin).
We will recommend which of these methods will be best for your individual case; and you will decide which option you desire. Each patient is unique; and we must individualize your treatment to achieve the best results. Repairs may be completed by us or by other surgical specialists. Most of the wound closures are performed immediately in our office while the site is still anesthetized. When the expertise of another surgical specialist is required, that reconstruction may take place on the same day or, usually, the next day. There is no harm in delaying reconstruction for several days. Also, if the reconstruction is to be extensive, that portion of the operation may require hospitalization. These arrangements are usually made beforehand during the preoperative evaluation; however, some tumors turn out to be more extensive than anticipated. In any case, we will do everything we can to schedule the repair at your convenience.
Your surgical wound will require care during the weeks following surgery. You will be given detailed written instructions on how to do this. You should plan on wearing a bandage and avoiding any strenuous activity for at least a week. Most patients experience minimal pain that usually responds to Tylenol. Aspirin (and the like) should be avoided until at least 2-3 days after surgery. You may experience a sensation of tightness (or drawing) after surgery or as the wound heals; but this is normal and will improve with time. Skin cancer sometimes involves nerves and it may take months before the sensation returns to normal. In some cases, the numbness may be permanent. During healing, the new skin that grows over the wound contains many more blood vessels than the skin that was removed. This results in a red scar that may itch or be sensitive. The healing process goes on for a long time (usually 12-18 months). Especially during the first few months, the site may feel thick, swollen, or lumpy. Gentle massage of the area (starting about two to four weeks after surgery) will speed the healing process. Any form of treatment will leave a scar. Mohs micrographic surgery tends to minimize scarring as much as possible by preserving as much normal tissue as possible. We make every effort to obtain optimal cosmetic results for you and work in conjunction with other surgical specialists; but our primary goal is to eradicate the tumor. Materials you will likely need for wound care:
- Non-stick pads (Telfa or Adaptic mesh gauze)
- Absorbent gauze or topper dressing
- Cotton-tipped applicators or Q-tips
- Paper tape or hypo-allergenic tape 5. Petroleum jelly
An indefinite follow-up period of observation is necessary after your wound has healed. You will be asked to return in 4-6 weeks, three months, six months, or annually thereafter, depending on the site, size and type of skin cancer removed. Your referring physician may handle your follow-up. It has been shown that once you develop a skin cancer, there is a significant chance of developing another. In the unlikely event that there is a recurrence of the skin cancer that was treated, it must be detected at once and managed. Experience has shown that if there is a recurrence, it usually will be within the first year following surgery. You will be reminded to return to your dermatologist on a regular basis for continued surveillance of your skin.
Risks Of Mohs Surgery
Each patient is unique; and it is impossible to discuss every possible complication and risk of surgery. The usual risks are discussed below; and any additional problems associated with your particular case will be addressed during the preoperative evaluation.
- The post-surgical defect may be larger than anticipated. We can only estimate before surgery how large this defect may be.
- There will be a scar. Again, Mohs surgery will leave you with the smallest wound possible, creating the opportunity for the best cosmetic result.
- There may be poor wound healing. Usually there is a reason (poor physical condition, diabetes, smoking, excessive bleeding, or other diseases). The wound may reopen or flaps and grafts used to repair the defect may fail. If this happens, the wound will usually be left to heal in on its own.
- There may be a loss of motor (muscle) or sensory (feeling) nerve function. This usually only occurs when tumor invades the nerve and it has to be removed with the cancer. We will let you know before surgery if there are any of these major nerves near your tumor.
- There may be loss of part or all of an important structure (eyelid, nose, lip and ear) with a resulting cosmetic or functional defect. Again, if the tumor involves these areas, it must be removed. Other specialists may need to be involved in the repair of the resulting defect.
- The wound may become infected. This is very rare; but if you are at particular risk for infection, you may be given antibiotics prior to and after surgery.
- There may be an adverse reaction to medications used (antibiotics, analgesics). You will need to let us know of prior allergic reactions; but new reactions to medications may occur as well.
- There may be excessive bleeding. This is usually controlled during surgery but may be a problem after surgery when you are at home. This is a rare occurrence as you are screened before surgery for bleeding problems and “blood thinners” are usually discontinued.
- The tumor may regrow after surgery. Previously treated and large, longstanding tumors have the greatest chance of recurring. Remember that all of the above occurrences are the exception and not the rule. If we feel that Mohs micrographic surgery is not the best alternative for managing your tumor, we will discuss other options. We also are not offended if you would like a second opinion and would be glad to recommend another specialist to you.
We do not think that sunshine is harmful to you as long as you use adequate protection and use discretion. As mentioned, sunlight is the main contributing factor in the development of skin cancer; and once you have developed one, there is a significant chance of getting another. We suggest the following:
- Try to avoid the sun between the hours of 10 AM to 4 PM.
- Apply a sunscreen with a sun protection factor (SPF) of at least 15 liberally.
- Apply to all exposed areas, including top of ears, hands, and feet.
- Apply the sunscreen about 15-20 minutes before going outdoors.
- Reapply liberally after swimming or excessive perspiration or after 3-4 hours.
- In addition to sunscreen, protective clothing (broad rimmed hat, sunglasses, and lightweight, tightly woven garments) can be very beneficial.
You may lead a normal life style if you take precautions and are sensible. For more information about skin cancer or Mohs micrographic surgery please go to the official ACMS website: www. mohscollege. org.
- DO notify us as soon as possible if you must cancel or change your appointment.
- DO plan on spending several hours with us (most cases take 2-3 hours).
- DO get a good night’s sleep.
- DO eat breakfast and take your usual medications (unless instructed
- DO dress comfortably and bring someone or something to occupy your time.
- DO let us know if you take blood thinners or antibiotics before dental procedures.
- DO ask any questions you might have.
- DO NOT consume alcohol 24 hours prior to and 48 hours after surgery.
C. Drew Claudel, MD
Dr. Claudel joined Rivergate Dermatology July, 1999. He is a native of Louisiana and received his medical degree at Louisiana State University Medical Center-Shreveport, LA. After completing Dermatology residency at Vanderbilt University, he spent an additional year in a formal fellowship training program for Mohs surgery with Dr. Edward Parry at LSUMC-New Orleans, LA. He is board certified in Dermatology and is a fellow of the American Academy of Dermatology, the American College of Mohs Surgery, and the American Society for Dermatologic Surgery.