Is Mohs Surgery Necessary After Malignant Growth Removal?

A Guide for Determining Necessity

When skin cancer appears, the approach for removal ranges from basic excision to the highly precise Mohs technique. Thoughtful assessment of the type, size and location of the malignancy along with the patient's profile guides practitioners on when Mohs is needed after initial tumor extraction.

Skin cancer is the most common type of cancer in the United States, with over 5 million cases treated each year. Basal cell carcinoma and squamous cell carcinoma, the two most common forms of skin cancer, are highly curable when detected and treated early. However, it’s crucial to remove these malignant growths completely, as any remaining cancer cells can lead to recurrence and spread.

When a dermatologist detects a suspicious growth on the skin, a biopsy is performed to analyze the cells and confirm a skin cancer diagnosis. Once it is diagnosed as malignant, the next step is surgical removal of the entire growth. There are several surgical techniques available, ranging from simple excision to the precise layer-by-layer removal offered by Mohs surgery.

This raises an important question: Is Mohs surgery necessary after initial malignant growth removal, or are other simpler methods sufficient? 

Schedule a consultation with our skilled dermatologists to determine the most effective surgical procedure for removing your basal or squamous cell skin cancer

Surgical Procedures for Basal and Squamous Cell Skin Cancers

There are three primary surgical procedures for removing basal cell and squamous cell carcinomas:

Electrodessication and Curettage (ED&C)

The cancerous lesion is scraped away using a curette instrument. An electric current is then applied to kill any remaining cancer cells in the treatment area.

Standard Surgical Excision

The malignant growth is cut out from the skin along with a surrounding margin of healthy tissue using a scalpel. The width of the excised margin depends on factors like the size and location of the tumor.

Mohs Surgery

The most complex but precise method. Here, the visible tumor is first removed along with a thin layer of surrounding tissue. This tissue is immediately examined under a microscope to check for presence of cancer cells at the margins. If found, additional tissue layers are excised and examined until the margins are clear.

Understanding Mohs Surgery

Mohs surgery is considered the gold standard for treating certain common skin cancers. It is named after Dr. Frederic Mohs, who developed this technique in the 1930s.

It involves surgically removing the visible tumor layer by layer, while examining the margins after each excision under a microscope until no cancer cells remain. Here are the detailed steps:

1. The visible tumor is removed along with a thin layer of clear margin around it.
2. This tissue layer is frozen, cut into sections, stained, and examined under a microscope by the surgeon to check if the margins are cancer-free.
3. If cancer cells are still present at the edge, the process is repeated on that specific area until the margins are definitively clear. This allows maximum preservation of healthy tissue.
4. Once cancer-free margins are achieved, the surgical site is reconstructed for optimal function and cosmetic outcome.

The Advantages of Mohs Surgery

There are several benefits that make it an invaluable technique:

• Highest cure rate: For basal cell and squamous cell carcinomas, Mohs has a 5-year cure rate of up to 99%, higher than other approaches.
• Complete margin control: Each excised layer is examined under a microscope by the surgeon while the patient waits, eliminating the need for return visits if margins are positive.
• Maximum preservation of normal tissue: Only cancerous areas identified under the microscope are removed while retaining adjacent healthy tissue.
• Minimal scarring: Spares as much healthy tissue as possible, allowing for smaller wounds and less scarring.
• Precision: Exact mapping and microscope guidance allows pinpoint removal of root-like growths around critical facial areas (eyes, nose, ears).

When Mohs Surgery is Recommended

Mohs micrographic surgery is strongly recommended and favored over other techniques for treating certain high-risk skin cancers:

	On the head and neck area, especially around delicate areas like eyes, nose, lips, ears, scalp, and temple.
	Basal or squamous cell cancers that have recurred after prior treatment. Recurrent tumors may have deep roots not visible on the surface.
	Aggressive subtypes like morpheaform and sclerosing BCC, which are prone to recurrence.
	Tumors with poorly defined or diffuse borders where exact tissue removal is vital.
	Large tumors > 2cm with higher risk of recurrence.
	In areas where maximal tissue preservation is key for functionality, like hands, feet, or genitals.

Have our team of Mohs experts customize a treatment plan if you have a recurrent, large or high-risk skin cancer. Book your consultation today

The Mohs Surgery Patient Experience: Managing Pain and Recovery

Undergoing Mohs surgery, like any procedure, may produce anxiety for patients around the potential pain and recovery process. However, most patients find the surgery comfortable and recover quickly with proper aftercare. 

Here is an overview of what patients can expect:

• The procedure itself is done under local anesthesia. Most patients experience only mild discomfort during the surgery.
• There is some pain, swelling, and bruising post-surgery, but it generally subsides within a few days. Most patients find it manageable with over-the-counter medications like acetaminophen.
• Recovery is quick, as adjacent tissue is preserved. Patients can usually resume normal activities soon after surgery.
• Wound care involves keeping the site clean, moisturized, and protected with a bandage until healed. Stitches, if present, are removed after 1-2 weeks.
• Full healing can take 2-4 weeks for smaller excisions, longer for larger reconstructions. Moisturizing the scar helps minimize scarring.

Risks of Mohs Surgery

As with any surgery, there are some risks, which are usually minimal in expert hands:

• Mild pain, bleeding, bruising, swelling after surgery that resolves quickly.
• A low risk of infection at the site, treated with antibiotics if it occurs. Proper wound care reduces this risk.
• Scarring, though typically minimal with precise tissue removal.
• Temporary or permanent numbness around the excision site.
• In very rare cases, nerve damage or impaired function if large tumors were located in functional areas like around the eyes, nose or ears.

Determining If Mohs Is Necessary After Initial Removal

The decision of whether to proceed with Mohs surgery after initial removal of a malignant skin growth requires assessing multiple factors:

1	The type of initial procedure performed matters - a well-executed standard excision or ED&C may successfully remove the entire growth.
2	For high-risk cancers, Mohs provides the greatest certainty of clear margins. It is often recommended in these cases.
3	The necessity depends on case particulars like location, size, risk profile, patient health status.

While not obligatory in every scenario, Mohs remains the most effective option for highest-risk skin cancers. 

Conclusion

While Mohs surgery is not necessary for every case of skin cancer, it is considered the most effective treatment for high-risk basal cell and squamous cell carcinomas, especially on the sensitive head and neck areas. 

Consultations with a dermatologist and Mohs surgeon can help determine if Mohs is the most suitable treatment option based on the patient’s unique presentation and needs. With early diagnosis and appropriate treatment, most cases of basal and squamous cell skin cancer can have an excellent prognosis.

Schedule an appointment with Dermatology & Skin Health today so we can determine the optimal treatment to eradicate your skin cancer completely with excellent prognosis