How Modified Mohs Optimizes Skin Cancer Removal

Innovations in technique allow more precise extraction of tumors, improved cosmetic results, and lower recurrence rates

Modified Mohs surgery removes skin cancers in stages, examining tissue samples under a microscope between surgeries. This technique carefully targets just the cancer cells and spares more healthy skin around the tumor.

For over 80 years, Mohs surgery has been the gold standard for removing complex skin cancers. Now, advances in Mohs techniques are optimizing outcomes even further. 

By enhancing precision and versatility, modified Mohs procedures are improving cure rates, minimizing scarring, and sparing healthy tissue around tumors. This transformative approach represents the next generation of skin cancer treatment.

Discover how innovations to the Mohs process are enhancing precision and improving patient experiences. Consult with Dr. Mendese today

Understanding Traditional Mohs Surgery

Developed in the 1930s by Dr. Frederic Mohs, traditional Mohs surgery involves removing the visible tumor layer by layer while assessing each layer under the microscope during the same surgical session. This allows the surgeon to track where the cancer cells are while minimizing removal of healthy tissue around the tumor.

During the procedure, the surgeon first removes the clinically evident tumor with a scalpel, creates a "map" to orient the tissue, and examines the margins under a microscope. If cancer cells are still present at the edges, the surgeon removes another tissue layer and repeats the process until no cancer cells remain. This methodical approach helps trace out the roots of cancers that are irregularly shaped or have grown along blood vessels or nerves.

Once the cancer is fully removed, the surgeon repairs the wound immediately with various reconstructive techniques like skin flaps or grafts. This all typically occurs as a single outpatient procedure lasting several hours.

What is Modified Mohs Surgery?

In traditional Mohs surgery, patients have to remain immobilized for the lengthy tissue removal and microscopic analysis process to be completed all in one day. To improve patient comfort and convenience, modified versions of the technique have been developed.

Modified Mohs surgery separates the tumor removal stage from the microscopic analysis. In the initial surgery, the physician removes the clinically visible tumor with narrow margins and creates a highly detailed "map" of the tissue. 

The tissue is then frozen or processed and stained to be examined under the microscope several days later.

If any residual cancer cells are found, the patient returns for a second smaller surgery to remove an additional tissue layer right at the positive margin site. 

This saves unaffected tissue since the surgeon knows the precise location needing re-excision. After verification of tumor-free margins, reconstruction immediately follows.

How Does Modified Mohs Surgery Work?

Modified Mohs surgery adds some preparation steps to facilitate the multi-session approach. As in traditional Mohs, the surgeon first marks off the clinically apparent tumor area. 

The margins are then expanded an additional 1-2mm for basal cell carcinomas and 4-6mm for squamous cell carcinomas. The outlined tissue is surgically removed, with care taken to orient the sample and map the exact anatomy.

Unlike standard Mohs, the tissue is then prepared with either frozen section processing or paraffin embedding to allow for microscopic analysis at a later date. In frozen section processing, tissue is frozen rapidly to harden for thin cutting and stained with fast dyes. With paraffin embedding, tissue is treated with paraffin wax to preserve architecture and stained with hematoxylin and eosin (H&E).

After the stained slide is microscopically reviewed, a final surgical treatment plan is formulated. If margins are clear, the wound can start healing. But if cancer cells extend to the edge, the patient returns for a targeted second-stage surgery to remove a 5-10mm strip right along the positive margin. This tissue is frozen or paraffin processed to confirm removal of all cancerous cells before repairing the wound.

Get a step-by-step overview of the modified Mohs technique and how it facilitates thorough margin analysis. Book your appointment with us

What Types of Skin Cancer Can Be Treated?

Modified Mohs surgery is suitable for certain common skin cancers when performed by an experienced Mohs surgeon.

Cancer Type	Description
Basal Cell Carcinoma (BCC)	Modified Mohs achieves 5-year cure rates exceeding 95% for this most prevalent skin cancer. Its precision makes it ideal for tumors on visually sensitive facial areas.
Squamous Cell Carcinoma (SCC)	Effective treatment option for select SCCs, particularly on the head and neck region. Cure rates may be slightly lower than BCC, especially for high-risk SCCs.
Melanoma and Rare Cancers	Not typically used for invasive melanoma or uncommon cancers like dermatofibrosarcoma protuberans. May be considered for early-stage melanomas (e.g. lentigo maligna) in some cases.

Consulting a qualified Mohs surgeon ensures proper patient selection and optimal outcomes with this technique. Careful analysis of each case helps maximize cancer cure rates.

Who Is a Good Candidate for Modified Mohs Surgery?

Certain skin cancer characteristics and patient factors affect candidacy for modified Mohs surgery:

Skin Cancer Characteristics

• Suitable for recurrent or aggressive basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).
• Especially effective for large tumors located on the head and neck.
• Ideal for cancers with indistinct edges that require precise mapping.
• Effective for tumors growing near or along nerve endings, blood vessels, or other critical structures.

Patient Factors

• Beneficial for patients who may have difficulty staying still during lengthy procedures or who face risks with prolonged anesthesia.
• Excellent for patients requiring maximum preservation of healthy tissue, particularly in cosmetically sensitive areas like the lips, nose, or eyelids.
• Modified Mohs is an efficient option for older adults or those with significant health issues who may not tolerate traditional Mohs surgery well.
• Convenient for patients traveling long distances to access a Mohs surgeon, as it reduces time spent in one session.
• Children can also be good candidates for modified Mohs surgery, as shorter initial procedures reduce the need for general anesthesia and lengthy immobilization.

When Is Modified Mohs Not Recommended?

Modified Mohs surgery may not be appropriate for every patient or tumor. In some cases, traditional Mohs or other modalities like surgical excision or radiation therapy may be preferred.

Factors where standard Mohs or other treatments may be advised include:

• Very small or well-defined basal cell or squamous cell carcinomas on the trunk or extremities
• Melanoma and other complex skin cancer types requiring broad margins
• Inflammatory conditions or cancers involving substantial portions of a tissue layer
• Need for extirpation of the entire lesion and examination of the complete specimen
• Lack of access to a skilled Mohs surgeon and specialized pathology support

Benefits of Modified Mohs Surgery

High Cure Rates

Modified Mohs surgery achieves excellent cure rates for common skin cancers like basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) that meet or exceed those of traditional Mohs techniques. Studies indicate cure rates of up to 99% for primary BCC and around 95% for high-risk or recurrent tumors with the modified approach. 

Tissue Preservation

By designing the removal process to spare healthy tissue, modified Mohs techniques maximize the preservation of normal surrounding skin compared to routine excisional surgery. The initial margins may be narrower, targeting just the tumor border. Any subsequent stages selectively remove additional cancerous edges rather than widely excising more area around the tumor site.

Low Recurrence Rates

The systematic and highly targeted nature of modified Mohs leads to very low recurrence rates for treated skin cancers. In one major study, the 5-year recurrence rate after modified Mohs was approximately 3% versus 8% after standard excision. This significantly reduces the risk of additional treatments and re-excisions.

Improved Cosmetic Results

Preserving more healthy tissue minimizes scarring, skin distortion, and deformity, especially around visually sensitive facial areas. Smaller wounds simplify repairs and reconstructions that blend with natural contours for optimal aesthetics. The conservation of healthy tissue enhances cosmetic outcomes with modified Mohs procedures.

Discover the many advantages modified Mohs offers for appropriate patients, from cure rates to cosmetic outcomes. Get in touch with Dermatology and Skin Health experts

Potential Complications and Side Effects

While serious complications are infrequent, modified Mohs surgery does carry some risks typical of any skin surgical procedure. These include:

• Bleeding is typically minimal, but in rare cases may require a blood transfusion.
• Post-surgical infections can occur, often requiring antibiotic treatment, and are one of the most frequently reported complications.
• Small sensory nerves may rarely be damaged during surgery, leading to temporary or permanent numbness or weakness.
• Larger or complex wound repairs have a higher likelihood of healing issues like wound separation or delayed healing, especially in older patients or those with certain medical conditions.
• Scars from the surgery may widen or thicken over time, sometimes necessitating revision surgery to improve appearance.
• Allergic reactions to anesthetics or surgical materials, though uncommon, can result in redness, irritation, or swelling at the injection site.
• While the possibility of residual cancer is low with modified Mohs, there remains a small risk of recurrence.

Careful surgical technique and proper wound care can help minimize these potential risks and complications. Patients should thoroughly discuss them with their surgeon when considering modified Mohs.

What to Expect During Recovery From Modified Mohs Surgery

Patients will have an open wound immediately after the initial modified Mohs surgery, which is typically repaired with sutures or reconstructed with a skin graft or flap. Swelling, bruising, and mild pain are common initially. Your surgeon will provide post-operative instructions on caring for the surgery site, medications, activity restrictions, and follow-up appointments.

Here is what to expect during the recovery process:

Time Frame	Description
Days 1-4	Swelling and bruising usually peak by day 2 and start improving by days 3-4. It is important to keep the wound area elevated and limit movement. Cold compresses can help reduce swelling. Take prescribed pain medication as directed and avoid strenuous activity for at least 1 week.
1-2 Weeks	Sutures are typically removed around 7-10 days post-surgery unless absorbable sutures were used. Swelling continues to decrease, and temporary numbness or tingling around the site is common. Gentle massage of the scar can begin 3-5 days after suture removal to help soften and flatten it.
2-6 Weeks	Most improvement in wound appearance occurs by 3-4 weeks. Patients can gradually advance their activity levels towards normal by around 2 weeks but should avoid contact sports or heavy lifting for 4-6 weeks. Sun protection on the scar site should begin after it fully seals, usually around 4-6 weeks post-op.
3-6 Months	The scar typically reaches maximal improvement by 2-3 months. Firmly massaging the scar 1-2 times daily for the first 3 months can aid in healing. Protecting the healing scar from sun damage during this period is crucial.

Follow all post-op instructions carefully, keep all appointments, and alert your surgical team regarding any worrisome symptoms. 

Call your doctor promptly if you observe expanding redness, pus, worsening pain, fever, or wound opening. Avoid smoking or nicotine products during recovery, as these impair healing.

• Ask about procedure volume - higher annual case numbers indicate more specialized expertise.

How to Choose a Qualified Surgeon for Modified Mohs

Optimal results require a surgeon highly skilled in Mohs techniques and specialized reconstruction. Consider these tips when selecting a surgeon:

Verify Board Certification: Ensure the surgeon is board certified in dermatology and has specific training in Mohs surgery through the American College of Mohs Surgery (ACMS) or the American Board of Dermatology.

Look for Fellowship Training: Choose a specialist who has completed a Mohs surgery fellowship, which typically involves 1-2 years of additional training focused on Mohs techniques and skin cancer treatment. This training is crucial for achieving high cure rates and optimal cosmetic outcomes.

Search for Accredited Surgeons: Use the American College of Mohs Surgery website to find properly accredited Mohs surgeons in your state or region. This ensures they have met rigorous training standards.

Consider Multidisciplinary Centers: Look for a Mohs surgeon associated with a multidisciplinary skin cancer treatment center that offers on-site pathology and reconstructive support. This can streamline the coordination of the multi-step process involved in Mohs surgery.

Schedule a Consultation: Meet with the surgeon to evaluate rapport, discuss case details, and review before-and-after photos of previous patients. This will help ensure you feel comfortable and confident in your choice.

Questions to Ask Your Doctor About Modified Mohs Surgery

When considering modified Mohs surgery, it is important to consult with a board-certified Mohs surgeon. Key questions to ask the surgeon include:

1. What are my treatment options besides modified Mohs surgery?
2. What is my specific skin cancer risk profile?
3. Will my cancer require one or two surgical stages?
4. What reconstruction technique do you recommend for optimal cosmetic results?
5. How much tissue do you expect to remove around the tumor?
6. What are the potential risks and complications based on my case?
7. What is the likelihood my cancer will be fully eradicated with this approach?
8. How will pain and wound care be managed after surgery?
9. How much postoperative scarring can I expect?
10. How much experience do you have specifically with modified Mohs techniques?

Don't hesitate to request clarification or additional details on any aspect of your proposed care. Being fully informed helps ensure you receive the best possible treatment and recovery.

Conclusion

Medical research continues to prove modified Mohs an effective option for appropriate candidates with basal cell or squamous cell carcinomas on sensitive facial regions. 

By providing precise removal and detailed margin analysis, modified Mohs surgery delivers better aesthetic and functional outcomes with excellent cancer control. 

Consult with an experienced board-certified Mohs surgeon at Dermatology and Skin Health to evaluate whether modified Mohs surgery is the right treatment option for your particular skin cancer and goals.

Schedule your appointment today