Dermatologic Mohs Surgery and Laser Therapy: A Combined Approach

The One-Two Punch Against Skin Cancer: Mohs Surgery + Laser Therapy

Laser surgery and Mohs surgery – you’ve probably heard these terms before in the context of dermatology. 

Does skin cancer surgery have to leave a visible mark? Not necessarily.  

Revolutionary advancements in dermatology mean you can eliminate cancer cells while minimizing the appearance of scars. Learn how Mohs surgery and laser therapy team up to fight cancer and restore flawless-looking skin.

What Is Mohs Surgery?

First, let’s clarify Mohs surgery. This specialized technique was developed in the 1930s by Dr. Frederic Mohs to treat skin cancer. It involves surgically removing the visible skin cancer, layer by layer until only cancer-free tissue remains. Here’s a quick rundown of how it works:

• The visible tumor is first removed along with a thin layer of surrounding skin.
• This tissue is frozen, stained, and examined under a microscope to look for remaining cancer cells at the edges.
• If cancer cells are still present, another layer is removed and examined.
• This process continues until there are no more cancer cells detected microscopically.

The primary advantage of Mohs surgery is the unparalleled accuracy in removing 100% of the skin cancer while maximally preserving healthy tissue. By taking tissue samples during the procedure and meticulously mapping the lesions, the surgeon can pinpoint exactly where the cancer ends.

This precision is especially critical for cancers located on sensitive facial areas like the nose, eyes, lips and ears. By sparing extra skin, Mohs provides optimal cosmetic outcomes in these highly visible regions.

Why Is Mohs Surgery Performed?

Mohs surgery is most commonly used to treat two of the most prevalent skin cancers:

• Basal cell carcinoma (BCC) - the most common skin cancer, typically slow growing and rarely spreads but can grow deeply into surrounding tissue.
• Squamous cell carcinoma (SCC) - the second most common skin cancer, a bit more aggressive than BCC and more likely to recur if not fully removed.

It is typically recommended for cancers that are:

• Recurrent after previous treatment
• Aggressive or fast growing
• Larger in size
• In sensitive facial areas like nose, eyes, lips, etc.
• In locations with minimal underlying tissue like fingers, ears, etc.

Mohs has cure rates up to 99% for these common skin cancers, which is higher than other treatments like surgical excision.

How Does Laser Surgery Differ from Mohs Surgery?

Now that we have a handle on Mohs surgery, how does laser surgery differ?

As the name suggests, laser surgery utilizes concentrated beams of light energy rather than a surgical scalpel. In dermatology, lasers can be used to:

• Remove certain benign growths and tumors
• Resurface the top layers of the skin
• Reduce wrinkles and scars
• Eliminate precancerous lesions
• Treat vascular lesions like spider veins

Unlike Mohs surgery, laser surgery does not remove tissue layers for microscopic analysis. However, it provides a more superficial treatment of the skin itself.

Some key differences between these two procedures:

• Purpose: Mohs for cancer removal vs lasers for skin rejuvenation
• Depth: Mohs removes deeper tissue layers vs lasers work on the skin surface
• Mechanism: Mohs is surgical excision vs lasers use thermal energy
• Procedure: Mohs is typically done in stages vs lasers can treat an area all at once

So in summary, Mohs surgery is a complex, methodical technique to eliminate skin cancer while laser surgery provides a more targeted approach to revitalizing the skin's appearance.

Can Mohs Surgery Be Combined with Laser Surgery?

Given their distinct approaches, is it possible to combine Mohs surgery with lasers? The short answer is yes, in certain circumstances, these two procedures can be successfully performed together in a complementary manner.

Here are a few examples of how lasers can enhance the results of Mohs surgery:

Improving Appearance of Surgical Scars

One of the most common uses of lasers after Mohs is for scar revision. Certain lasers like CO2 or Erbium lasers can minimize scarring by resurfacing the top layers of skin around the Mohs surgery site.

Reducing Recurrence Risk

In some cases, lasers may be applied after Mohs surgery to target any remaining cancerous cells and reduce the chances of recurrence.

Treating Extensive Lesions

For large lesions, Mohs surgery may first be used to remove the bulk of the tumor. Lasers can then eliminate any remaining scattered cancer cells.

Managing Pre-Cancerous Lesions

Lasers can also treat actinic keratoses and other precancerous lesions to possibly prevent the development of a more invasive cancer requiring Mohs surgery.

So in the right circumstances, lasers can be a powerful complement to Mohs surgery, enhancing outcomes and improving long-term prognosis.

How Are Lasers Used to Improve Scarring After Mohs Surgery?

While Mohs surgery offers high cure rates for skin cancer, the procedure can sometimes leave noticeable scars. However, various laser treatments offer excellent options for minimizing the appearance of scarring post-Mohs. Here's an overview of the most common types of lasers used:

Fractional CO2 Laser

This is one of the most powerful choices for treating Mohs surgery scars. It works by creating tiny microthermal zones of damage, triggering a deep healing response that stimulates collagen production and remodels the skin. Benefits include:

• Significant scar reduction
• Smoothing of uneven skin texture
• Improvement in skin tone

Pulsed Dye Laser (PDL)

This targets blood vessels and is highly effective for reducing redness and improving the overall appearance of scars. Benefits include:

• Diminished discoloration
• Reduction in raised, hypertrophic scars
• Potential to help prevent some raised scarring

Erbium:YAG Laser

This laser generally works on the more superficial layers of the skin. Benefits include:

• Skin resurfacing for smoother texture
• Minimizing the appearance of fine lines and wrinkles around the scar

Important Considerations:

• Timing is essential: Laser treatment shouldn't happen too soon after surgery. The wound needs time to heal, and your doctor will advise on the optimal point for laser intervention.
• Multiple sessions are typical: Achieving the best result may require a series of laser treatments spaced over time.
• Choosing a provider: It's crucial to select a dermatologist experienced in using lasers for post-Mohs scar treatment to ensure optimal safety and results.

What Are the Benefits of Combining These Procedures?

Utilizing lasers in conjunction with Mohs surgery offers a range of potential benefits:

• Better healing: Lasers improve the overall appearance and texture of the surgical site for optimal healing. Collagen production and new skin growth are stimulated.
• Enhanced cosmetic results: Scarring, skin discoloration and textural irregularities can all be minimized with laser techniques. This is especially impactful on highly visible facial areas.
• Lower recurrence rates: As mentioned, lasers may help reduce the risks of skin cancer returning after Mohs by eliminating stray cancer cells.
• Increased precision: The combined approach maximizes the removal of cancerous tissue while protecting healthy skin, especially around delicate areas like the eyes.
• Improved patient experience: Lasers allow for less invasive procedures with shorter recovery times compared to extensive Mohs surgery alone.
• Treatment of pre-cancers: Lasers can take care of precancerous lesions before they require complex Mohs procedures.
• Versatility: Lasers can treat multiple types of lesions in varied locations, complementing the precision of Mohs for aggressive cancers.

Overall, lasers deliver better cosmetic outcomes with potentially improved skin health when combined strategically with Mohs surgery.

What to Expect During Combined Mohs Laser Surgery

If your dermatologist recommends Mohs surgery paired with laser therapy, here’s an overview of what to expect:

• The Mohs surgery will be performed first to remove the bulk of the skin cancer. Local anesthesia is used to numb the area during this procedure.
• Once the margins are clear of cancer cells under the microscope, the laser procedure will follow in the same area to “clean things up”.
• With lasers, you’ll wear protective eyewear. The laser will be carefully targeted at the treatment area in a painless, gentle beam.
• Some lasers involve direct contact with the skin, while others are applied just above the surface. The sensation is often described as a rubber band snapping on the skin.
• Treatment time depends on the size of the area, but most laser procedures take less than an hour.
• Mild discomfort, redness, and swelling are common after laser therapy. Your dermatologist will provide post-procedure instructions for optimal recovery.
• Temporary bruising or oozing can occur. Bandages and antibiotic ointment are often applied, with stitches rarely needed.
• Some peeling and crusting may happen as the skin exfoliates over the following week. Cleanse gently and avoid picking at scabs.
• Healing is usually quick, with results continuing to improve over the next few months. Schedule follow-ups as advised.

Lasers used with Mohs surgery are very well tolerated with minimal downtime. Still, it’s vital to follow your dermatologist’s advice closely after the procedure.

Who Is an Ideal Candidate for Combined Surgery?

For those considering Mohs plus laser therapy, here are some factors that can determine if you are an ideal candidate:

• Skin cancer type and extent – The specific type of tumor and how far it extends beneath the skin impacts how lasers can complement Mohs treatment. A detailed clinical exam is needed.
• Location on the body – Using lasers for highly visible areas on the face or neck tends to provide the greatest cosmetic enhancement after Mohs.
• Skin tone – Lasers work best on lighter skin. Darker skin carries higher risks of pigment changes or scarring. Adjustments to settings and wavelengths can help account for this.
• History of keloids – Those prone to keloid scarring may not be suitable for lasers after surgery. Lasers can potentially worsen keloids.
• Bleeding risks – If you have bleeding/clotting disorders or take blood thinners, lasers may not be advisable as they can induce oozing from treated areas.
• Unrealistic expectations – While lasers can offer substantial improvements, they cannot erase scars completely after extensive Mohs procedures. Maintain realistic expectations about results.

Have an open discussion with your dermatologist about your suitability. With their expertise, they’ll guide you on expected outcomes.

Recent Advances in Combined Mohs Laser Techniques

Both Mohs surgery and laser therapy have seen significant advances. Here are some of the latest innovations that are transforming dermatologic surgery:

Next-Gen Lasers

• Picosecond lasers: These ultra-short pulsed lasers better target pigment while minimizing collateral skin damage. Picosecond technology is now used in tattoo removal and scar treatment lasers.
• Fractional lasers: These create tiny perforations in the skin, allowing deeper penetration of light energy with accelerated healing. Fractional lasers treat scars, wrinkles and pigment irregularities.
• Multimodal platforms: Lasers like Discovery Pico allow various customizable treatments from skin rejuvenation to acne scar reduction using different wavelengths and delivery methods.

Enhanced Mohs Techniques

• Second-pass Mohs: After traditional Mohs surgery, treated areas are immediately re-excised to minimize recurrence risk.
• 3D immunostaining: Special stains and immunofluorescent imaging give greater accuracy in analyzing excised Mohs tissue layers.
• Micrographic surgery automation: Advanced digital systems like MART-1 are being developed to analyze Mohs samples with artificial intelligence, improving speed and precision.

Novel Combined Approaches

• Pre-Mohs laser: Lasers first debulk tumors, allowing more conservative and rapid Mohs removal.
• Immunotherapy + laser: Laser disruption of tumors activates the immune system combined with medications like immune checkpoint inhibitors.
• Mohs + laser + PRP: Injecting platelet-rich plasma into laser treated sites after Mohs maximizes regeneration and healing.

As technology progresses, expect to see novel pairings of laser techniques and Mohs surgery elevate patient outcomes to unprecedented levels.

Conclusion: A Powerful Combination for Skin Health

Dermatologic Mohs laser surgery brings together the unparalleled precision of Mohs with the cosmetic skin enhancement of lasers. When thoughtfully combined, these treatments allow skin cancers like basal and squamous cell carcinomas to be eliminated with minimal scarring or recurrence risk.

Patients can realize rejuvenated, healthy skin, especially on delicate facial areas. Technological breakthroughs continue to unlock new possibilities in results and recovery times. Close consultation with a board-certified dermatologist experienced in utilizing these procedures together ensures the greatest benefit.

While no single approach fits every patient, the strategic integration of Mohs surgery with advanced laser therapy affords a tremendous opportunity to confront skin cancer with confidence while achieving optimal aesthetic outcomes.