Mohs micrographic surgery is a specialized, highly effective technique for the removal of skin cancer. The procedure was developed in the 1930's by Dr. Frederic Mohs and is now practiced throughout the world. Mohs surgery differs from other skin cancer treatments in that it permits the immediate and complete microscopic examination of the removed cancerous tissue, so that all roots and extensions of the cancer can be eliminated. Due to the methodical manner in which tissue is removed and examined, Mohs surgery is recognized as the skin cancer treatment with the highest cure rate of any treatment available, 99%. This procedure, utilizing the most exact and precise method of cancer removal, minimizes the chance of re-growth and lessens the potential for scarring with skin cancer suregry. For most new skin cancers the cure rate is 99%. While the success rate in treating a recurrent skin cancer (previously treated cancer) by conventional means is often as low as 50-80%. The success rate for Mohs surgery in treating recurrent skin cancers remains high at 95-98%.
Qualifications of the Mohs surgeon
It is important that you verify that your Mohs surgeon is recognized as a fellowship-trained surgeon. This can only be done through the Mohs College website: www.mohscollege.org . Board-certified dermatologists who are fellowship-trained in Mohs surgery have specialized skills in dermatology, dermatologic surgery, dermatopathology, and Mohs micrographic surgery. In addition, the fellowship-trained Mohs surgeon must have the required surgical and laboratory facilities, and be supported by a well-trained Mohs staff. The American College of Mohs Surgery (ACMS) is the only certifying body in America that requires extensive training ( over 500 cases per year) as well as demonstrated proficiency in complex plastic surgery reconstruction and experience managing rare and difficult tumors. This one to two year fellowship training can only occur following the successful completion of a dermatology residency and board-certification in dermatology. The surgical training is performed under the direct supervision of a fellowship Director recognized and approved by the American College of Mohs Surgery. Most doctors have not done this extensive training. Dr Allen was trained in dermatology and did his fellowship training in Mohs surgery and cosmetic surgery at the prestigious Washington University in St Louis, Missouri. He completed his combined fellowship in Mohs surgery and cosmetic surgery in 2005. He has performed well over 3000 Mohs cases with reconstructive surgery..
Qualifications of the Mohs Surgery Clinic
In addition to verifying that your Mohs surgeon is board-certified and fellowship-trained, it is also important to investigate the qualifications of the Mohs surgical clinic. The tissue processing lab at Dermatology Specialists of Boulder is one of a handful of Mohs and tissue processing labs in Colorado that has been CLIA certified (Clinical Laboratory Improvement Amendments) at the highest level of complexity. This means that the DSB lab is inspected regularly by the State of Colorado, and must comply with the high standards established by the Colorado Department of Public Health and Environment. Dr. Allen's surgical staff is knowledgeable and highly trained in assisting him Mohs surgery. Our facility is suited to accommodating Mohs patients and their families while they are here. Our Mohs patients and their families wait between surgeries in a private waiting room where they can enjoy a cup of coffee or light snacks while they wait.
Advantages of Mohs surgery
Some skin cancers can be deceptively large and far more extensive under the skin then they appear to be from the surface. These skin cancers may have roots in the skin, or along blood vessels, nerves, or cartilage. Skin cancers that have recurred following previous treatment may send out extensions deep under the scar tissue that has formed at the side as well. Mohs surgery is specifically designed to remove these cancers by tracking and removing these cancerous roots in their entirety. Other forms of skin cancer removal cannot predict precisely how much skin needs to be removed and wide safety margins are utilized. Studies have shown that between 180-350% excess tissue is removed with traditional surgical excision of skin cancers when compared to Mohs surgery. Therefore, Mohs surgery results in the highest cure with the most healthy tissue conserved. The patient should bear in mind that Mohs surgery removes only the cancerous tissue, while the normal healthy tissue is spared, in most cases resulting in a smaller scar.
Indications
Mohs Micrographic Surgery is most frequently used to treat basal cell carcinomas and squamous cell carcinomas, but is also ideal to treat less common skin tumors. Mohs surgery is always indicated when:
• The cancer was treated previously and recurred.
• Scar tissue exists in the area of the cancer
• The cancer is in an area where it is important to preserve healthy tissue for maximum functional and cosmetic result, such as the face, eyelids, nose, ears, lips, fingers and toes
• The cancer is large
• The edges of the cancer cannot be clearly defined
• The cancer is growing rapidly or uncontrollably
Patient Preparations for Surgery
It is important that you obtain a good night's rest and eat normally on the day of the Mohs surgery. If you are taking prescription medications, continue to take these unless otherwise directed by a physician. However, to help avoid excessive bruising or bleeding you should avoid taking aspirin-containing medications for ten days prior to your surgery if your doctor will allow you to stop. You also should avoid aspirin substitutes (such as Advil, Motrin, Aleve, Naprosyn, etc.) within 5 days of surgery. Tylenol, however, may be taken at any time prior to surgery as it does not thin your blood. For your comfort, it is recommended that you wear casual, layered clothing on the day of your surgery. You may also wish to bring a book or magazine to help occupy your waiting time. We do provide coffee and snacks for you while you wait.
Duration of Procedure
Most Mohs surgery cases can be completed in two or fewer stages, requiring less than 3 hours. Howerver, it is not possible to predict how extensive a cancer will be, as the extent of a skin cancer's roots cannot be estimated in advance. Therefore, it is advisable to reserve the entire morning for this surgical procedure, in case the removal of additional layers is required. Please note that the majority of your time spent at the office is in the waiting area, not on the surgical table. We use local numbing shots only so you are fully awake. Again, bring a book or some work to do while you are waiting for your cancer slides to be clear.
Minor Post-Surgical Discomfort Expected
Most patients do not complain of significant pain. If there is some discomfort, normally only Tylenol is required for relief. If you require something stronger please inform us.
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Wound Healing, Scarring, and Scar Revision
As with all forms of surgery, a scar will remain after the skin cancer is removed and the surgical area has completely healed. Mohs micrographic surgery, however, will leave one of the smallest possible defects and resultant scars. Sometimes, wounds allowed to heal on their own result in scars that are barely noticeable. Even following extensive surgery, results are frequently quite acceptable and scars may be hard to find. In addition, scars do have the ability, through the body's own natural healing properties, to remodel and improve in appearance for a 24-month period after the surgery. There are also many other techniques available to the patient for enhancement of the surgical area following skin cancer surgery. A raised or roughened scar may be smoothened or softened by using laser resurfacing or chemical peeling techniques. Dr Allen is considered an expert in reconstructive surgery for repairing surgical defects and is a national speaker on how to optimize the cosmetic outcome following Mohs surgery.
Potential Complications Associated with Mohs Surgery
Patients should understand that there is not an absolute guarantee that any given procedure will be totally free of complications or adverse reactions. Mohs surgery is no exception. During surgery, tiny nerve endings are cut, which may produce a temporary or permanent numbness in and around the surgical area. If a large tumor is removed or extensive surgery is required, occasionally a nerve to muscles may be cut, resulting in temporary or permanent weakness in a portion of the face. This is, however, an unusual and rare complication that can usually be avoided. The surgical area may remain tender for several weeks or months after surgery, especially if large amounts of tissue were required to be removed. Rarely, some patients experience intermittent itching or shooting pain in the surgical area for 12 to 16 months after skin cancer surgery. In addition, rarely the skin grafts and flaps used in plastic surgery to cover surgical areas may not fully heal at first, requiring additional repair or laser procedures or just tincture of time.
Mohs Surgery Procedure Step-By-Step
Mohs surgery is performed as an outpatient procedure in the physician's office. Office based procedures help to keep the medical cost at a minimum and the safety at a maximum. Only local numbing medicine is required( no general anesthesia). Although the patient is awake during the entire procedure, discomfort is usually minimal and no greater than it would be for more routine skin cancer surgeries or your initial biopsy.
Step 1
The area to be treated is cleansed, marked, and injected with a local anesthetic. The Mohs surgeon removes the visible cancer, along with a thin layer of surrounding tissue. Following this procedure the patient may return to the waiting room while tissue is being processed and examined by Dr. Allen. Dermatology Specialists of Boulder houses an on-site, state-of-the-art CLIA certified lab to evaluate tissue specimens safely, rapidly and effectively.
Step 2
The removed tissue specimen is cut into sections, stained, and marked on a detailed diagram. A reference map is created.
Step 3
Tissue is frozen on a cryostat, and the technician removes very thin slices from the entire edge and under-surface. These slices are then placed on slides and stained for examination under the microscope. (This is the most time-consuming portion of the procedure. During this time, you may be bandaged and in the Mohs waiting room with coffee, tea, snacks available to you while you wait.)
Step 4
The Mohs surgeon carefully examines the entire under-surface and complete edges of the specimen, and all microscopic roots of the cancer are precisely identified and pinpointed on the Mohs map. Upon microscopic examination, if residual cancer is found, the Mohs surgeon utilizes the Mohs map to direct the removal of additional skin cancer. (Note that additional tissue is removed only where cancer is present.)
Step 5
This process is repeated as many times as necessary to locate and remove any remaining cancerous roots.
Step 6
When microscopic examination reveals that there is no remaining tumor, the surgical area is ready to repair.
What Happens After the Skin Cancer is Removed?
At the end of the Mohs surgery, you will be left with a surgical wound. This wound will be dealt with in one of several ways. The options will be discussed with you in order to provide the best possible functional and cosmetic results. Dr. Allen carefully examines you after Mohs surgery to determine which method will leave you with the smallest, least noticeable scar. The possibilities explained below include: healing by granulation (no stitches); closing the wound with straight line stitches, using a skin graft or using a skin flap (plastic surgery). Please ask to see photos of Dr Allen's previous repair work.
Closing the Wound with Stitches
This is the most common way to fix a defect. This involves some adjustment of the wound and sewing the skin edges together. This procedure speeds healing and can offer a good cosmetic result. For example, the scar can be hidden in a wrinkle line. Sutures are usually removed at one week or dissolvable sutures may be used.
Skin Grafts
This involves covering a surgical site with skin from another area of the body. The skin is usually removed from behind the ear or around the collarbone or in some cases from adjacent skin (this is called the donor site), and stitched to cover the wound. The donor site is then sutured together to provide a good cosmetic result. A bandage covers the graft for one week.
Skin Flaps
This involves movement of adjacent, healthy tissue to cover a surgical site. Where practical, they are chosen because of the excellent cosmetic match of nearby skin. Stitches are then removed in one week.
Healing by Granulation
This involves letting the wound heal by itself and offers a good chance to observe the wound as it heals after removal of a difficult tumor. Experience has taught us that there are certain areas of the body where nature will heal a wound nicely. Healing time is 6-8 weeks. There are also times when a patient may wish to allow a wound to be left to heal knowing that if the resultant scar is unacceptable, some form of cosmetic surgery can be performed at a later date.
Follow-up
You will need to return to Dermatology Specialists of Boulder in one week for stitch removal. If the area did not require sutures then you may be expected to return in 2 weeks for a wound check. Regardless of the repair performed, we like to see patients back at 6 weeks for a final check of the surgery site. At this point, if you were referred to us by another physician you will return to them for long-term follow up. If you do have any concerns with the surgical site in the future, please call us and make an appointment for re-evaluation as soon as possible.
Before and After Photos Below Click Here
