Mohs Micrographic Surgery

What Is Mohs Micrographic Surgery?

MOHs surgery

Mohs micrographic surgery (also known as Mohs chemosurgery) is a state-of-the-art treatment for skin cancer in which the diseased area is removed with the accuracy and precision of a microscope. Of all techniques to remove skin cancer, Mohs micrographic surgery has the highest cure rate and minimizes the extent of scarring. Mohs surgery is a one day, outpatient treatment which is generally reserved for use only with certain skin cancers. Those that are large, have recurred following conventional treatment, or those found in certain anatomic locations such as the central face are very effectively treated with this technique. Mohs surgery is utilized most often for the treatment of basal cell carcinoma, squamous cell carcinoma, and lentigo maligna (an early form of melanoma usually occurring on the face). However, the Mohs technique is also useful for other, less common forms of skin cancer, including sebaceous carcinoma, merkel cell carcinoma, atypical fibroxanthoma, microcystic adnexal carcinoma and dermatofibrosarcoma protuberans.

In the Mohs micrographic method, the doctor serves as surgeon, pathologist, and reconstructive surgeon. The technique, created by Dr. Frederick Mohs, is as follows:

  • A local anesthetic (usually lidocaine) is injected around the skin cancer.
  • The visible portion of the skin cancer is surgically removed.
  • The physician then removes a thin layer of tissue around the edges and at the base of the cancer.
  • The tissue is dyed to distinguish between top and bottom and left from right. A drawing, or map, is made so that the physician can pinpoint any areas of persistent tumor.
  • The tissue is then sectioned into very thin slices so that the edges and underside can be examined with a microscope.
  • If the tissue is found to still contain cancer, the physician outlines on the map the exact areas of involvement. Additional tissue is then removed only from the specific area(s) of involvement, thereby preserving as much healthy tissue as possible and minimizing the degree of scarring. The specimen is again processed in the laboratory, and the cycle is repeated as many times as necessary until no cancer cells remain.
  • After ensuring that all the cancer has been removed, the surgical area is usually closed with sutures (stitches) utilizing either a skin flap, skin graft, or an elliptical closure in order to optimize the aesthetic and functional outcome.

What Are The Advantages Of Mohs Micrographic Surgery?

  • Highest cure rate possible
  • Minimizes the amount of healthy, undiseased skin removed
  • Lowest functional and cosmetic morbidity of any procedure
  • One day outpatient surgery using local anesthesia

Preparation for Mohs Micrographic Surgery

When a patient arrives at our office for Mohs, any last minute questions or concerns can be addressed before getting started. A more formal consultation to discuss the operation can be scheduled in the days and weeks before surgery if a patient would prefer OR if the referring physician feels that it is necessary.

Prior to surgery, we recommend that patients get a full night’s sleep and (unless told otherwise) eat a light breakfast. The procedure is performed entirely on an outpatient basis in our office. The laboratory work involved in preparing the tissue for microscopic interpretation is labor-intensive and can take up to 1 – 2 hours or more to complete for each layer. Most patients bring a book or something to do while waiting on the results. We ask each patient to plan to spend the rest of the day with us, but some patients may be finished earlier.

If you are known to have cardiovascular disease and have been prescribed aspirin, Plavix, or Coumadin by your physician, it is not necessary to discontinue it, unless you are told otherwise. If you have not been prescribed aspirin or other blood thinners by your physician for the treatment of known cardiovascular disease, avoid aspirin for at least 7 days prior to surgery and for 2 – 3 days after surgery. All patients should try to avoid other NSAID’s (non-steroidal anti-inflammatory drugs), such as Advil/Motrin/ibuprofen, Naprosyn/Aleve/naproxen, and similar medications, and vitamin E as these medications also increase the tendency of bleeding. Plain Tylenol may be taken if pain medicine is needed. Be sure to check with your primary care physician prior to discontinuing any prescribed medications. A patient should also not drink any alcoholic beverages for two days before surgery and for one to two days afterwards.

Your Recovery – Return To Health And A Healthy Lifestyle

Immediately after surgery and during the recovery period, there will often be the sensation of tightness as well as soreness of the treated area. The area can also become very swollen and bruised depending on the extent of involvement. A variable degree of transient numbness of the area is generally expected due to nerve involvement, but complete and permanent loss of nerve function is rare. The incision line(s) typically improve in appearance over the first three to six months postoperatively, especially if exposure to the sun is avoided. Because the Mohs surgeon removes only the diseased tissue and as little healthy tissue as possible, the extent of scarring (which normally occurs after any surgery) is kept to a minimum.

It is important that patients take every precaution following Mohs micrographic surgery for skin cancer. In particular, adhering to a strict sun avoidance program helps to reduce the risk of further skin cancers. It is also important that patients be carefully monitored on a regular basis by their primary dermatologist after surgery. Research has shown that if there is a recurrence of skin cancer, it usually occurs within the first year. Furthermore, a significant percentage of patients who develop one skin cancer will get another within the next five years. Prevention and early detection are key.

Preoperative Instructions for Mohs Micrographic Surgery or Excisional Surgery

  • Your surgery will be performed in our office on an outpatient basis.
  • For patients having Mohs micrographic surgery, plan to possibly spend most of the day in our office (infrequently, it may be all day). This does not mean that you will be in surgery the entire time.  We do all of the laboratory testing while you wait in order to minimize the chance of tumor recurrence.  The lab work takes time, so you may want to bring something to read or someone to keep you company.  While waiting on laboratory results, you may return to our patient reception area to be with your family and/or friend(s) where coffee and snacks are provided.  Patients who are NOT having Mohs will NOT have to wait on the laboratory results.
  • Eat a light meal before coming in for surgery.
  • If you are known to have cardiovascular disease and have been prescribed aspirin, Plavix, or Coumadin by your physician, it is not necessary to discontinue it, unless you are told otherwise. If you have not been prescribed aspirin or other blood thinners by your physician for the treatment of known cardiovascular disease, avoid aspirin for at least 7 days prior to surgery and for 2 – 3 days after surgery.  All patients should try to avoid other NSAID’s (non-steroidal anti-inflammatory drugs), such as Advil/Motrin/ibuprofen, Naprosyn/Aleve/naproxen, and similar medications, and vitamin E as these medications also increase the tendency of bleeding.  Plain Tylenol may be taken if pain medicine is needed.
  • TAKE YOUR REGULAR MEDICINES on the morning of surgery, except as discussed above.
  • If not provided to us previously, please bring a list of all medicines that you are currently taking.
  • Avoid drinking alcohol for 2 – 3 days prior to surgery and for 2 days after surgery as this increases the chances of bleeding.
  • If you are diabetic, please bring a snack. If you have asthma, please bring your inhalers.
  • We use only local anesthesia, so you will not be put to sleep. A mild sedative (such as Valium) can be provided if desired, as long as you have someone drive you home.
  • Take a bath or shower using an antibacterial soap on the morning of your surgery. We recommend that you do not apply makeup on the morning of your surgery (if the surgical site is on your face).
  • Wear comfortable clothes. You will be asked to remove your shirt and a gown will be furnished.  Therefore, button-down shirts are preferable and one-piece garments (i.e., jumpsuits) are discouraged.
  • We recommend that you bring someone with you or have someone available to call in order to drive you home after your surgery, especially if the surgical site is on your face or near your eye.
  • If you have questions or want to cancel your scheduled appointment, please call and speak to our surgery coordinator as soon as possible.

Click here for more information about our affiliate – Skin Cancer Specialists Surgery Center, LLC.