This patient information and photographs on Mohs Micrographic surgery is provided by John L. Meisenheimer, M.D. a board certified Dermatologist and skin care specialist based in Orlando, Florida. This information is not intended as a substitute for the medical advice or treatment of a dermatologist or other physician.
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What is Mohs micrographic surgery? Mohs surgery, also known as Mohs micrographic surgery is a highly effective surgical technique for the removal of skin cancer. This specialized procedure was developed in the 1930's by Dr. Fredrick Mohs and is now well accepted by the medical community world wide. Mohs surgery differs from other skin cancer surgery in that the surgeon also serves as the pathologist allowing for immediate and, most importantly, complete microscopic evaluation of removed cancer. The method employed to examine the tissue allows for better elimination of cancer roots. Mohs surgery is currently recognized as a skin cancer treatment with the highest cure rate. Because less tissue has to be removed compared to traditional surgery Mohs may allow for better final cosmetic results.
How the Procedure is done? Dr. Meisenheimer will first mark the area of cancer to be treated with a sterile surgical marker. The area to be removed will be anesthetized using a combination of a short and long acting local anesthetic. You will not be put to sleep or sedated, only the area to be treated is anesthetized. Dr. Meisenheimer will then remove tissue and create a map of the area treated. The tissue removed will be transferred to a histology lab in our office where the tissue will be processed and mounted on slides.
This processing takes from 30 minutes to over and hour depending on the circumstances. During this time you may read, watch TV have a friend or family member sit with you. There will be a bandage on the treatment area at this time and occasionally you may have to apply pressure to the area.
Dr. Meisenheimer will then read the slides to make sure all the cancer is clear from the margins. If the cancer is clear then he will discuss with you options for cosmetic repair of the defect. Most surgical defects will be repaired by Dr. Meisenheimer on the same day.
If there is still remaining cancer when the slides are read, Dr. Meisenheimer, will identify the location on the surgical map return and take more tissue only from the area involved. This process is repeated until the cancer has been completely cleared.
Why Mohs surgery? Skin cancers can be deceptively small on the surface of the skin, much like an iceberg, where only the tip shows, much more can be below the surface. Cancers may have roots and just cutting off the top will not get rid of the roots. Recurrent skin cancers following previous treatments may send out roots deep under the scar. Mohs surgery is designed to treat cancers by tracking out the cancerous roots. Because of this, prior to Mohs surgery, it is impossible to predict how much skin will have to be removed. The final surgical defect may be only slightly larger than the initial skin cancer but occasionally the roots are extensive and could results in a sizable defect. Keep in mind though that Mohs surgery removes only the cancerous tissue, while normal skin is spared.
Special indications for Mohs surgery It is important to know that Mohs surgery is not used for the treatment of all skin cancers. Even if you have a basal cell carcinoma or a squamous cell carcinoma Dr. Meisenheimer may not always recommend Mohs surgery. Mohs micrographic surgery is typically used in those skin cancers that have recurred following previous treatment and for cancers that are at high risk for recurrence such as aggressive growth patterns and indistinct margins. Mohs surgery is also used for cancers where preservation of healthy tissue is critical such as the face, nose, ears, eyelids, lips, hairline, hands, feet and genitals.
Insurance coverage for Mohs surgery Medicare and most insurance companies cover the cost of Mohs surgery and repair, if needed, following removal of the cancer. Please contact your insurance carrier for the most current coverage information related to this treatment. If you contact our office billing we may be able to help you with your questions.
Patient preparation for surgery Continue to take prescription medicines unless otherwise directed by your doctor. If your primary care doctor will let you stop any blood thinners that you are on this would be of benefit. Please check with your doctor though before stopping any medicines. If you are taking aspirin you need to be off it at least one week for it to lose its blood thinning effect. Please let Dr. Meisenheimer know if you are taking blood thinning medicines such as Coumadin, Plavix, or other anti-inflammatory medicines such as Aspirin, Ibuprofen, Advil, Motrin, Naproxen, etc. Please also let us know if you are taking nutritional supplements or vitamins such as Vitamin-E, Ginkgo, Garlic, Ginseng, Ginger, etc. These medicines and supplements may sometimes cause an increased chance of bleeding after surgery.
It is important that you eat normally on the day of your surgery. We recommend you wear casual layered clothing. You may also want to bring a light snack and book/magazine to help occupy your waiting time. We also recommend that you arrange for somebody to drive you home following surgery. Please plan on scheduling your entire day for the Mohs procedure. Although the majority of Mohs cases are completed in an hour or two, a few cases may require your being in the office for several hours and this can not be predicted in advance.
Options for post surgical reconstruction After the skin cancer has been removed Dr. Meisenheimer will discuss the following options with you:
• A cosmetic repair of the wound defect by Dr. Meisenheimer (This is the most common scenario)
• Allow the wound to heal naturally without the necessity for additional surgery
• Reconstruction which cannot be done in the office with referral to another surgeon for wound repair.
You will be given detailed instructions following your surgery regarding your wound care. Some sites, cosmetic repair by suturing the sides of the wound together may be required, however, in some areas of the body there is little tissue that can be stretched for coverage of the wound and either a skin graft or flap may be used. In closing wounds with a skin flap, the skin adjacent to the surgical defect is partially cut free and moved to cover the surgical area. Stitches are then placed to hold the flap in its new position. Other areas may require skin graft to provide coverage. Skin from the side of the neck, behind the ear or over the collar bone may be cut free, placed over the wound and then sewn into place. The original site of the graft is then closed with stitches and allowed to heal. Dr. Meisenheimer is very experienced in performing cosmetic reconstruction following skin cancer surgery having done thousands of complex repairs, grafts and flaps over the last two decades. Post-Operative care instructions.
Wound healing, scarring and scar revision As with all surgery, the skin repairs itself with scar tissue formation. Our goal is to minimize this scarring to make the final scar as in perceivable as possible. By using Mohs micrographic surgery the surgical defect and resultant scar will be minimized compared with conventional excision. Scars do have the ability through the body's own natural healing ability to remodel and improve cosmetically for six to twelve months after the surgery. There are many other procedures available to the patient for enhancement of the surgical area following the skin cancer surgery. Depressed or indented scars may be elevated using collagen or hyaluronic filler implants or subcision. Likewise, a raised or roughened scar may be smoothed using lasers and other techniques. Skin flaps and grafts may require subsequent touch up procedures to further improve their appearance. Many patients choose to do optional laser rejuvenation treatments over the surgical area to help improve finial cosmesis.
Potential complications associated with Mohs surgery Please be aware that there are not guarantees that any given procedure will be free of complications or adverse reactions. As with all medical decisions, there are no risk free options. During any skin surgery, superficial nerve endings are cut which may produce temporary or permanent numbness around the surgical area. If a large tumor is removed or extensive surgery is required occasionally nerves to muscles may be cut resulting in temporary or permanent weakness in a portion of the face. This is however, an unusual complication. The surgical area may be tender for weeks or months following surgery, especially if large amounts of tissue are removed. Occasionally, some patients may experience intermittent itching or shooting pain in the surgical area. In addition, skin flaps and grafts used to cover surgical areas may not fully survive requiring additional repair. As with all surgery there is risk for infection, wound dehiscence (pulling apart of the wound edges) and spitting subcutaneous sutures or suture abscesses.