MOHS MICROGRAPHIC SURGERY

Mohs Micrographic Surgery

The Cosmetic Skin and Surgery Center now offers the state-of-the-art Mohs Micrographic Surgery, a procedure designed for the effective removal of skin cancer, headed by Dr. Matthew B. Quan, our resident Mohs surgeon. This procedure was designed in 1930s to remove certain skin cancers that are unresponsive to more traditional treatments and therapies by Fredrick Mohs, M.D. of The University of Wisconsin. A special fellowship is a requirement of the American College of Mohs Micrographic Surgery and Cutaneous Oncology to become a Mohs surgeon. A certified histotechnologist is also employed to work alongside the Mohs surgeon. Tissue specimens are processed by the histotechnologist, while the Mohs surgeon functions as both pathologist and surgeon.

Your skin cancer may require special treatment, which is why may you have been referred to our surgical suite for Mohs surgery.
To effectively treat skin cancer, there are several methods available. Size, tumor type, location, and previous treatments are some of the factors that determine the choice of treatment. Mohs surgery is known to have the highest cure rate for both primary and recurrent cancers, and is often used on basal and squamous cell skin cancers. The very complex Mohs surgery procedure involves a combination of surgical excision and on-the-spot microscopic examination of the tissue specimen with processing techniques using frozen tissue. The five steps involved in the process are as follows:

A local anesthetic, Lidocaine, is used to numb the skin.
A thin, bowl-shaped layer of skin which contains the tumor is surgically removed.
In the laboratory, the specimen is sliced and divided, and subsequently mapped, numbered, color-coded, sectioned, and stained.
The Mohs Surgeon then determines if the entire tumor has been removed by examining each section microscopically.
The skin defect is then repaired once complete removal of the tumor is confirmed. However, steps 1, 2, 3, and 4 are repeated if traces of the tumor still remain.

With Mohs surgery, the entire surgical margin is examined, and we will be able to identify and locate any leftover cancer, if the tumor is still present. This means that if we need to remove another layer of skin, we are able to do so in the precise area of the remaining cancer. This ensures that normal, healthy skin remain untouched. Mohs Surgery may need to be performed in multiple stages because some skin cancers are very complicated. It takes approximately 60 minutes to examine each stage. The entire day must be reserved for this surgery as the Mohs procedure may take a while, especially with multiple stages involved.

How To Prepare For Your Surgery?

At least 2 weeks before your surgery, do not take any medication that thin the blood, such as aspirin (or anything that contains aspiring) and vitamin E. Be sure to check with your physician if he/she puts you on aspirin. For pain or headaches, Tylenol is advised.
We need to be informed if you have metal screws or pins or artificial valves or joints installed, as well as if you require antibiotics for dental or other procedures, so we can prescribe them for you. These will need to be taken at least an hour before your Mohs surgery.
You may take all of your routine medications as normal, unless otherwise specified. If you have been prescribed Coumadin (another blood thinner), you will need permission from your prescribing physician if it is safe to discontinue it.
To help pass the time quicker, bring something for reading.
We recommend asking a friend or relative to go with you to help you pass the time, as well as to keep you company when you go home. Driving after the procedure is strongly discouraged since the bulkiness of the dressing may hamper your mobility or vision.
On the day of the surgery, you may eat a normal lunch or breakfast. You may also bring your own food for snacks.
Alcoholic drinks should not be consumed at least two days prior to the surgery.
Do not wear one-piece outfits. Comfortable dark clothing with buttons down the front is strongly recommended.
Wash your hair and take a shower before your surgery. If surgery is being done on your face, do not apply makeup.
After your surgery, please refrain from taking any trips and other such important events for several weeks.
Resting is very important, exercise and other strenuous physical activity must be avoided for one to two weeks.

Please expect some scarring. Unfortunately, some skin cancers may be larger than what you can see, so the scars may be significantly larger, as well. Removing all the cancer on the same day that you come in is our primary goal. After the cancer is removed, we will do our best to leave you as cosmetically intact as possible.

What To Expect The Day Of Surgery?

Because of the complex nature of the Mohs Surgery process, some delays stemming from adjustments are not uncommon. Your patience and understanding is greatly appreciated.
Once you are checked in at the office, you will be taken straight to the Mohs surgical suite. Feel free to ask question before the procedure begins. Also, if there’s anything we can do to increase your comfort, let us know.
You may feel a bit of discomfort when Dr. Quan injects the local anesthetic to numb the area around the tumor. Additional injections that may be needed later will be a lot less painful and may even be entirely painless.
Dr. Quan will begin to remove the thin layer of cancerous skin once the area is numb. This is Stage I, and mapping, color-coding, and dividing this first layer of skin immediately commences. Any bleeding is stopped using an electric needle and the wound is then dressed.
Within the next hour, the histotechnologist will work alongside Dr. Quan to process and examine the tissue microscopically.
Dr. Quan will then repeat the procedure, if the microscopic examination shows that skin cancer cells still remain. The area still affected will then be divested of additional tissue.
On average, the stages are repeated 2 or 3 times until all the cancer is gone.
The defect is repaired as soon as the skin cancer has been removed completely. Stitches in a linear fashion usually suffice in closing the wound. This results in a straight line for a scar, instead of a circular hole. In some cases, the hole may be left open to heal on its own, or a complicated skin graft may be applied, depending on the size, location, and depth of the wound. As soon as the cancer is full removed, Dr. Quan will be discussing the options with you. In a week or two, the stitches can then be removed.

For one to two weeks after the surgery, keeping your head elevated with an extra pillow while resting or sleeping is advised, if the cancer is on the face. By doing so, swelling is reduced significantly. After your procedure, you may end up with one or two black eyes if the cancer is close to your eyes with the worst being three days after the fact. Although no additional treatment is necessary, it helps to apply cold compresses. Weeks or even months of fastidious wound care is required after the stitches are removed, even if the site looks well. We reiterate not planning any trips or important social events for several weeks following your surgery.