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Mohs Micrographic Surgery

Introduction

In 1937, Dr. Fredrich Mohs, Professor of Surgery at the University of Wisconsin and Nobel Prize in Medicine Nominee, developed a technique for the microscopically controlled surgical removal of skin cancers known as chemosurgery.  When first developed, Mohs’ surgeons’ applied a chemical to the skin.  Today, chemicals are no longer used and the surgery is now known as micrographic surgery.  Mohs’ Micrographic Surgery is a very time consuming procedure and requires highly specialized training and personnel.  This technique provides patients’ with skin cancer the highest chance for cure.  Even very complicated, recurrent cancers are effectively treated greater than 95% of the time with Mohs’ Surgery.  Patients with skin cancer that have not been previously treated with other techniques can expect a 98% cure rate utilizing Mohs’ Surgery.

THE STAFF AT DERMATOLOGY AND SURGERY OF SOUTHERN OHIO

The Mohs’ Micrographic Surgery Unit at Dermatology & Surgery of Southern Ohio consists of several individuals who will be involved in your care.  In addition to Dr. Grevey, there are specially trained surgical assistants who are experienced in caring for patients with skin cancer.  These individuals are experienced and knowledgeable about any problem which may arise.  Additional members of our team include laboratory technicians who precisely prepare the tissue for microscopic examination.  Our front office staff consists of receptionists, secretaries, and our office manager.  Should you have any questions about billing policies or need assistance in filing insurance forms, our front office staff can provide assistance.

WHAT IS SKIN CANCER?

Cancer is a tissue which grows at an uncontrollable and unpredictable rate.  There are three main forms of skin cancer.  Basal Cell Carcinoma, Squamous Cell Carcinoma, and Malignant Melanoma.  These names refer to the specific cell of the skin from which the cancer originates.  Mohs’ Surgery is commonly utilized to treat these three types of skin cancer.  However, Mohs’ Surgery may be utilized to treat other very rare types of skin cancer.

ARE SKIN CANCERS DANGEROUS?

The most common types of skin cancer are Basal Cell Carcinoma and Squamous Cell Carcinoma.  Both types generally grow and enlarge locally from the point of origin and usually do not spread (metastasize) to other parts of the body.  A skin cancer left untreated will continue to grow causing destruction of the skin and any structures present in the path of growth.  Skin cancers will not go away on their own.  A skin cancer that has been partially treated or incompletely removed will continue to grow and often result in a larger and deeper cancer.  Compared to other forms of cancer, skin cancers are generally discovered at an early stage.  Therefore, patients with skin cancer have a greater chance of cure.

Malignant Melanoma is the third most common form of skin cancer.  The incidence of Malignant Melanoma is rising faster than any other skin cancer.  More than 75% of all deaths attributed to skin cancer are caused by Malignant Melanoma.  Fortunately, the diagnosis is often made early which allows for effective and curative treatment.  Delay in the diagnosis or treatment of any skin cancer may result in a greater loss of healthy tissue and require a more extensive surgery.

WHAT CAUSES SKIN CANCER?

The causes of skin cancer, like other forms of cancer, are not entirely known.  Sun exposure is the single most important factor associated with the development of skin cancer.  Fair-skinned individuals with red or blonde hair and blue eyes are more susceptible to the development of skin cancer than dark-skinned individuals.  Skin cancer also tends to be hereditary and occurs with increased frequency in certain ethnic groups such as Northern Italians and Northern Europeans.  Sun-exposed areas of the body (head, neck and arms) are the most common locations for skin cancer.  However, skin cancer can occur anywhere on the body.  Other possible causes of skin cancer include x-ray therapy, trauma, old burn scars, and certain chemical and insecticides that may contain arsenic.

MY SKIN CANCER HAS BEEN PREVIOUSLY TREATED.  WILL I EVER BE CURED?

Frequently, patients are referred to Mohs’ surgeons because previous treatments were unsuccessful in curing their tumor.  Using microscopic examination, the Mohs’ surgeon can pinpoint areas involved with cancer and selectively remove only those areas.  Mohs’ Surgery utilizes microscopic control to search out the roots of the cancer, thus achieving the highest chance of cure for the patient.  Mohs’ Surgery can even cure patients with skin cancer that have persisted despite several other treatments.  Mohs’ Surgery allows a greater than 95% cure rate where other forms of therapy have only a 40 to 60% cure rate.

WHAT ARE THE ADVANTAGES OF MOHS’ SURGERY?

Using microscopic examination, the Mohs’ Surgeon can pinpoint areas involved with cancer and selectively remove only these areas.  This results in the removal of as little healthy tissue as possible, yet allows the highest chance for cure.  Mohs’ Surgery is performed under local anesthesia and does not require the need for general anesthetics.  Because the removal of healthy tissue is minimized, the resulting defect created by the removal of the tumor is usually smaller.  This often allows for an easier reconstruction of the defect.

HOW EFFECTIVE IS MOHS’ SURGERY?

Mohs’ Surgery can achieve cure rates greater than 98% for skin cancer that has not previously been treated by other methods.  Patients with recurrent skin cancer that has been treated with other methods can expect a greater than 95% chance for cure with Mohs’ Surgery.

HOW IS MOHS SURGERY PERFORMED?

Initially, Dr. Grevey will explain the planned surgery and answer any last-minute questions that have not been answered.  With a surgical marking pen, Dr. Grevey will mark on the skin the area planned for surgical removal.  Anesthesia with local anesthetics will then be administered.  A slight burning sensation is noted with the local anesthetics and typically, that is all the pain you will feel.  Dr. Grevey will then remove the visible portion of the tumor with a curette or scalpel blade.  A second thin layer of tissue beyond the initial layer is then removed.  Prior to tissue processing, the specimens’ are stained with colored tissue dyes and a detailed map is drawn indicating the exact location from which the specimens were removed.  All tissue specimens are processed in our laboratory.  The processing of the tissue generally takes approximately 2-4 hours.  Dr. Grevey will then examine each tissue specimen under the microscope for any residual tumor.  If residual tumor is detected during microscopic examination, the precise mapping and tissue staining allows the Mohs’ surgeon to identify the exact location of the residual tumor.  If residual cancer is present, the entire procedure is repeated, however, only those areas with remaining cancer are removed.

Most cancers require two to three trips to the operating room for complete removal.  Very large, longstanding, aggressive or recurrent tumors may take longer. Each stage of the surgical procedure requires approximately 3 hours (1 hour for surgery and 1 to 2 hours to process the tissue for microscopic examination).  Again, several surgical steps may be required.  Plan on being at the office all day.  In rare instances, the patient may have to come back the next day to have the process completed.

WILL THE SURGERY LEAVE A SCAR?

Yes.  Any form of treatment for skin cancer usually will leave a scar.  Mohs’ Micrographic Surgery preserves as much normal tissue as possible.  Mohs’ surgeons remove only tissue involved with cancer.  Healthy tissue not involving tumor is not removed.  As a result, the defect created during surgery is often smaller which allows for a less involved reconstruction to repair the wound.  Every effort to obtain an optimal result for the patient is considered.  On occasion, a multispecialty team of doctors may be needed to work in conjunction with the Mohs’ surgeon to maximize an optimal result for the patient.

DOES IT HURT?

A local anesthetic, usually Xylocaine, is injected around the skin cancer to anesthetize the skin.  A slight discomfort is experienced initially until the skin becomes numb.  Once the numbness has begun, no discomfort is experienced.  Anesthesia generally will keep patients pain-free for several hours.  If additional stages of surgery are required, additional Xylocaine may be injected to keep patients pain-free.  After the surgery is completed, most patients experience very little discomfort; however, a prescription for pain medication will be provided.  Generally, regular Tylenol is all that is needed for most patients.

WILL I NEED TO BE HOSPITALIZED?

No, probably not.  Mohs’ Surgery is performed as an outpatient procedure in our office.  Only rarely do Mohs’ Surgery patients need hospitalization; however, if necessary, patients can be admitted to the hospital.  If we feel that hospitalization would be best for you, we will inform you of this during the initial evaluation.

WHAT HAPPENS AT THE PRE-OPERATIVE VISIT?

The pre-operative visit allows Dr. Grevey the opportunity to examine your skin cancer, obtain any pertinent information, and discuss Mohs’ Surgery in further detail.  The pre-operative visit allows you the opportunity to learn more about the procedure and to ask any questions.  Every skin cancer is different, and because of the high demand for Mohs’ Micrographic Surgery, careful scheduling is necessary.  Patients referred from out of town may be scheduled for surgery at the time of their initial visit and not require a separate pre-operative visit.

Because all skin cancers are not alike, we need to know exactly what type of skin cancer you have before we can decide how to best proceed.  Most patients referred to us for surgery have had a biopsy (removal of a piece of tissue) and a pathology report indicating the type of skin cancer present.  If this information is not available, a biopsy will usually be preferred at the initial visit.

HOW SHOULD I PREPARE MYSELF FOR MOHS’ SURGERY?

Try to get a good night sleep, eat a light breakfast, and arrive at the office on time.  Make-up, facial lotions, and moisturizers should not be applied to the skin prior to surgery.  Due to the rise in bacterial infections in the past few years, we ask that you wash the area where the surgery will be performed with Dial Antibacterial Soap.  We ask that you use the Dial Soap to the surgical site once daily for 3 consecutive days prior to the scheduled procedure as well as the morning of.  If you are taking any medications, take them as usual unless our office tells you otherwise.  If you are taking Persantine, Coumadin, Plavix, Pradaxa, Xarelto, Brilinta, Aspirin or Aspirin containing products , these medications are usually stopped prior to surgery.  If you are taking any of those medications, please notify the office.  We will contact your medical doctor prior to stopping these medications.  Below is a list of medications that may thin the blood and should be avoided:

Alka Seltzer                 Bufferin                       Cheracol Capsules

Anacin                         BC Powder                   Coricidin

Aspirin                         Children’s Aspirin        Chondroitin

Dristan                        Fish Oil                        Omega 3

Ecotrin                         Garlic                          Vanquish

Excedrin                      Glucosamine               Vitamin E Oil

Flax Seed Oil               Midol                           Ticlid

Aspirin interferes with the ability of your blood to clot.  If you need a pain medication, take Tylenol or acetaminophen.  Do not drink alcoholic beverages for 3 days before or after surgery.  Alcohol causes the skin to flush and interferes with the clotting process of the blood.  Medications prescribed for arthritis can also potentially interfere with the ability of your blood to clot.  Below is a list of arthritic medications which should be avoided at least 1 week prior to surgery:

Advil                Diclofenac                   Meclomen                   Ponstel

Aleve               Disalcid                       Midol IB                       Sulindac

Anaprox           Ibuprofen                    Mobic                          Toradol

Arthrotec         Indocin                        Motrin                         Trilisate

Celebrex          Indomethacin              Nebumetone               Vicoprofen

Cramp End      Ketoprofen                  Nalfon                         Voltaren

Daypro            Lodine                         Naprosyn

If you are taking any medication for pain or arthritis that is not included on the list, please let us know.

If you have had a history of any joint replacements, valve replacements, any pins, screws, stents or ports, any history of rheumatic fever or valvular heart disease; you will need to be pre-medicated with an antibiotic prior to the scheduled procedure.  Please make the staff aware if this applies to you.

Newspapers, magazines and other reading materials are available and provided.  The office can become cool and a blanket can be provided.  Bring a sweater just in case!

SHOULD SOMEONE COME WITH ME ON THE DAY OF SURGERY?

Yes! We suggest you bring someone to accompany you to keep you company during the procedure and to drive you home.  If this cannot be arranged, please let us know.  Public transportation, taxi, or shuttle service may need to be arranged.  Do not plan on driving yourself home after surgery.  If surgery was performed near the eyes or a sedative was required, you will not be able to drive.  In consideration of other surgery patients, we ask that no children accompany you to the office on your surgery day.

WHAT HAPPENS ON THE DAY OF SURGERY?

Appointments for surgery are usually scheduled early in the day.  It is important to arrive on time or a little early.  After you arrive, an assistant will escort you to the surgery area, blood pressure and other vitals will be obtained.  The nurse will then prepare the area planned for surgical removal.  Dr. Grevey will then answer any last minute questions you or your family members may have.  Next, the cancer to be removed will be outlined with a marking pen, local anesthetic is then injected into the surrounding area to anesthetize the skin.

Dr. Grevey will then carefully remove a thin layer of skin around the tumor, after the tissue has been removed, bleeding will be stopped with a cauterizing machine, and this machine makes a buzzing sound and generates some heat; however no discomfort is experienced.  A nurse will then place a bandage over the open wound and escort you to the reception area.  The removed tissue is immediately sent to our laboratory for processing.  Generally, it takes approximately 30 minutes to anesthetize the skin and remove the tissue.  Processing the tissue for micrographic surgery is very technical and time-consuming.  It will take 2 to 4 hours to prepare the tissue for microscopic examination; however, it may take longer.  While you are waiting for the results, you are free to leave the office.  There are a variety of restaurants in close proximity to our office.

If examination of your tissue reveals tumor cells present at the surgery site, the Mohs’ procedure will be repeated and the tissue again examined.  Only the tissue containing residual cancer is removed.  Several surgical excisions and microscopic examinations may be necessary and will be performed throughout the day.  Seldom is it necessary for the patient to return the following day for additional surgery.

HOW MANY SURGICAL SESSIONS WILL BE REQUIRED?

Most patients average two to three surgical sessions for removal of their skin cancers.  By mid-afternoon, most patients will have had their tumor completely removed.  Once the skin cancer has been completely removed, a decision is made on how to close the wound created by the surgery.  Dr. Grevey will discuss the various options available to reconstruct the wound.  Usually, Dr. Grevey will repair the wound immediately with stitches; however, grafting may be required.

WHAT IF THERE IS BLEEDING AFTER SURGERY?

A small amount of oozing and bleeding from the incision is normal after surgery, uncommonly; a patient may experience some bleeding after they leave the office.  If this occurs, lie down and apply steady, firm pressure directly over the wound.  Pressure should be applied directly over the area that appears to be oozing blood.  Apply continuous, firm pressure for 20 minutes.  While applying pressure, do not interrupt before 20 minutes, to see if the bleeding has stopped.  Remember 20 minutes of continues pressure almost always will cause the bleeding to stop.  Do not remove the bandage to check for bleeding.  If the bandage placed in the office has become soiled, you may apply an additional layer of dressing.  The original dressing that was placed in the office can be removed the following day.  If bleeding persists after 20 minutes of continuous, steady pressure, call Dr. Grevey immediately.

WHAT TO EXPECT THE FIRST FEW DAYS AFTER SURGERY.

Most surgical sites will develop an area of redness, mild swelling, and will be tender.  This is normal and will gradually resolve.  Initially, all wounds will have a small amount of oozing of blood or pink-tinged fluid which is normal.  You should call the office if this should occur.

Surgery performed around the eyes or on the forehead above the eyebrows will result in swelling and bruising of the eyes.  This is a normal response and will resolve in 5 to 7 days.  Bruising around the area of surgery can occur.  Cool compresses or cold packs may be helpful.

WHAT HAPPENS AFTER THE WOUND IS HEALED?

You may experience a sensation of tightness (or drawing) as the wound heals, but this is normal.  After several weeks, you will feel this is less and less.  Frequently, skin cancers involve the nerves of the skin.  During removal of the skin cancer, these nerves may be cut.  It may take a year or more after surgery before the feeling returns to normal.  Sometimes, the area never returns to normal and the numbness is permanent.

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, and the area may be sensitive to temperature changes.  This sensitivity improves with time and the redness gradually fades.  However, if you experience discomfort, try to avoid extremes of temperature.

New skin lacks the ability to protect from the sun.  A sunscreen with a sun protection factor 15 or higher should be used at all times.

Some patients may experience dryness or itching after the wound has healed.  The new skin that covers the wound does not contain as many oil glands as previously existed.  Skin moisturizers will help to relieve the itching.

HOW OFTEN MUST I RETURN FOR FOLLOW-UP, ONCE THE WOUND HAS HEALED?

After surgery, patients are evaluated 1 week later for removal of the stitches.  After the stitches are removed, we like to observe patients once more, usually 2 to 3 weeks later.  These follow-up visits can be arranged in our Fairfield or West Chester office if this would be more convenient.  Periodic visits during the first year after surgery are essential and observation for at least 5 years is recommended.  Our policy is to have patients return to their referring physician for the periodic and yearly visits.

Studies have shown that once you develop a skin cancer, there is a high risk that you will develop others in the years to come.  We recommend that you have at least yearly evaluations.  If a new skin cancer is detected, treatment can be provided.  We encourage all of our patients to begin examining their skin on a regular basis.  Should any suspicious areas be detected, have your doctor evaluate these areas to determine if a biopsy is necessary.

MUST I TOTALLY AVOID THE SUN?

No, not entirely.  We do not think that sunshine will be harmful as long as you provide yourself with adequate protection.  Attempt to schedule outdoor activities avoiding the times when the sun is at peak intensity.  This is usually between 11:00 am and 3:00 pm.  Even on days that are cloudy or overcast, damaging ultraviolet rays can penetrate and cause photo-damage.  Therefore, we encourage the daily use of a sunscreen with a sun protection factor of 15 or higher, to be used year round.

Sunlight is probably the main cause of skin cancer, and patients who have developed one skin cancer have an increased risk of developing another one at a later time.  Therefore, regular use of sunscreens is recommended.  In addition to a sunscreen, you may wish to wear a wide-brimmed hat and utilize clothing to further protect yourself from the sun.  Yes, you may lead a normal lifestyle.  Taking the necessary precautions and protecting yourself from the sun may prove to be beneficial in time to come.

WILL MY INSURANCE PAY FOR MOHS’ SURGERY?

Yes, almost always.  You may want to contact your insurance company to make sure.  Mohs’ Surgery is a very time consuming and labor intensive surgery that requires surgical suites and a highly complex laboratory.  Therefore, Mohs’ Surgery is fairly expensive; however, most commercial insurance will pay at least 80% of the cost and some will cover 100%.  We accept Medicare Assignment, which generally covers 80% of their accepted charge.  The remaining 20% co-payment will be the patient’s responsibility.  If you have a secondary insurance policy or co-insurance, this almost always covers the co-payments and deductible.

We ask that you bring all insurance cards and policy numbers with you to the office.  We will file all Medicare and insurance claims and request that your insurance company reimburse us directly.  If you have any questions regarding our billing policies or fees, please do not hesitate to contact our office.

SUMMARY

Mohs’ Micrographic Surgery provides the greatest chance of cure for even the most complicated of skin cancers.  Utilizing this surgical technique, we are able to spare as much normal skin as possible.  This may allow for an easier, more optimal reconstructive procedure.  Because this procedure is performed under local anesthesia, the risks are quite small, even in patients who have other complicated illnesses.  The wound healing from this surgery is excellent; however, if further cosmetic surgery is necessary, we are able to work closely with several excellent plastic surgeons in the area.

It is our hopes that this information provides answers to many of your questions. If you should have further questions, do not hesitate to contact our offices.