Mohs surgery is a technique developed by the late Dr. Frederich Mohs in Wisconsin. Frustrated by the frequent rate of skin cancer recurrence for many skin cancers removed by standard surgical techniques or other procedures (i.e. radiation, electrodesiccation & curettage, etc), he set out to develop a new way of both removing and processing the tissue in order to provide 100% margin control. Mohs surgery by definition is when the surgeon acts as both the surgeon and the pathologist. If a physician other than the physician who removed your skin cancer is the one to physically look at your surgical specimen under the microscope, then by definition this is not Mohs surgery. This is the only technique where the entire surgical margin is evaluated. It has the highest cure rate, 95-99%, of all skin cancer treatments.
Standard excisions, or surgical removal of tissue that does not use the Mohs technique will often process the tissue in a bread loafing manner. To better understand this, imagine a loaf of bread with raisins in it. If we took a slice or two of the bread to see what was in the bread, we may miss the raisins and consider the bread to be plain bread. Now let’s translate that to the medical world. Basically, checking the margins on skin cancer that has been removed by standard excision technique, and not the Mohs technique, evaluates <5% and some people have claimed <1% of the margins!! Depending on the location, size of skin cancer, or the type of skin cancer, this may not be good enough. Fortunately, Mohs surgery offers 100% margin control. As a result of our ability to evaluate 100% of the surgical margins, we are thus able to excise less skin, making the procedure much more conservative in nature. If after evaluating the surgical specimen slides, the physician discovers that there are still some areas where there is remaining tumor, the physician will map out the tumor with accuracy down to a hair follicle and remove a small amount of additional tissue. This process repeats itself until the tumor is completely removed and ready for suturing.
Mohs surgery is reserved for special circumstances due to the increased level of care that comes with this procedure. Certain criteria are used to determine which skin cancers would benefit from this procedure the most. Location (i.e. head, neck, hands/feet, genitals), size of the skin cancer, type of skin cancer, and some extenuating circumstances (including, but not limited to <40 years old, immunosuppression, certain genetic syndromes, recurrent skin cancer, skin cancer caused by radiation) are the most common categories for determining the appropriate use of Mohs surgery.
To read more about this treatment and the options for skin cancer please visit our page on Skin Cancer at: https://www.skinwellnessflorida.com/skin-cancer/
At Skin Wellness Physicians we employ and only endorse fellowship-trained Mohs surgeons who are recognized by the American College of Mohs Surgery (ACMS). Other organizations, such as the American Society of Mohs Surgery, offer abbreviated courses to certify in Mohs Surgery. The American College of Mohs Surgery requires at least a year long fellowship that is strictly dedicated to the training of Mohs Surgery and the expertise in reconstruction necessary to repair the surgical defect left behind following the removal of the skin cancer. A large number of complex cases during the fellowship are required to receive certification at the end of the fellowship and membership into the American College of Mohs Surgery. All clinical trials performed exemplifying the superior cure rates of Mohs Surgery (95-99%) for skin cancer above all other skin cancer treatments, were done exclusively by fellowship-trained Mohs surgeons. In order to ensure the highest quality of skin cancer surgical care, we strongly recommend that you have a Mohs College member performing your surgery. Their website can be found at http://www.skincancermohssurgery.org
A list of the members of the Mohs College can be found at:
Mohs Surgery Frequently Asked Questions:
- ARE THERE ANY OTHER IMPORTANT DETAILS I SHOULD KNOW?
- We recommend you bring a sweater or jacket because our office is often kept at cooler temperatures.
- A friend or family member for support is a good idea. If you are having surgery near the eye, on your hand, or on your nose, you may want to consider having someone be a driver for you because the post-operative bandage may interfere with you being able to drive home. If you require a driver, but are unable to have a friend or family member drive you, your local American Cancer Society (www.cancer.org) chapter will often have volunteer drivers available for patients requiring cancer treatments.
- Our medical team will process your arrival and once brought back by our clinical staff, you will be provided time to ask any additional questions so that you can make a comfortable, informed consent prior to beginning the Mohs surgery. The surgeon will then enter the room and mark the area that is to be removed. He will confirm the site with you and the clinical staff will then gently anesthetize the surgical site. Once numb, the surgeon will then return to the room to perform the surgery. Following each stage of the procedure (which takes 45-60min), you will be bandaged and escorted back to the waiting room while we process your tissue. Coffee, drinks, and refreshments will be available for you in our waiting area.
- WHAT CAN I EXPECT AT THE OFFICE ON MY SCHEDULED SURGERY DATE?
Please expect and plan to be here all day. Often times 2-4 hours can be expected, however, Mohs Surgery is frequently unpredictable and requires a substantial amount of time to remove the skin cancer. There are many factors that can lead to a prolonged surgery day which include, but are not limited to challenges processing the tissue, large tumors that require multiple stages to completely remove the cancer or more time to process it, or individual patient needs.
- WHAT HAPPENS WHEN MY MARGINS ARE CLEAR AND ALL OF THE TUMOR HAS BEEN REMOVED?
At this point the clinical staff will bring you back to the procedure room and prepare you for the closure of your wound. More than 80% of the time, a straight line will be used to close the wound. Occasionally, a flap or rearrangement of the tissue will be required to close the wound. This will result in a more geometric arrangement of suture lines and not just a straight line. This is done because of where the tumor was located or how large the tumor was so the best cosmetic outcome is provided by hiding the suture lines in existing skin wrinkles, creases, or folds. Rarely a skin graft is used when the aforementioned treatments are not applicable. Lastly, we commonly may allow for the wound to heal in on its own…let mother nature do the job. Less than 1% of the time we may need to collaborate with another surgical specialist to provide tertiary surgical services. This is something that would be discussed with you at your surgery visit or consult.
- ARE THERE ANY SUPPLIES I WILL NEED FOR MY AFTER-CARE?
Depending on the location and extent of your surgery, we will likely recommend some wound care for you to do at home once you remove the bandage. Some useful supplies to have on hand are:
- Hydrogen peroxide
- White vinegar (cheapest store brand available is just fine)
- Non-adherent (non-stick) gauze pads
- A clean container of Vaseline or white petrolatum
- Paper tape
- Tylenol for pain (we try to avoid ibuprofen because it can add to some post-operative bleeding)
- And depending on whether you swim frequently, some water-proof bandages
- DO NOT USE ANTIBIOTIC OINTMENTS BECAUSE OF THEIR FREQUENT CAUSE OF ALLERGIC SKIN REACTIONS
- Additional instructions will be provided to you by the clinical staff prior to your discharge from the office.
- WILL I NEED ANY ANTIBIOTICS OR PAIN PILLS?
We commonly will prescribe antibiotics prior to surgery or after surgery depending on the location, type of repair, or other extenuating circumstances. Pain pills may be prescribed depending on whether the physicians feels the post-operative pain will be inadequately controlled by over-the-counter Tylenol. Less than 5% of the time do patients require prescription narcotics for post-operative pain control.