Mohs Surgery

Dr. Mohs recognized that skin cancer often resembles the “tip of the iceberg” with more tumor cells growing downward and outward into the skin like the roots of a tree. These “roots” are not visible to the naked eye but can be seen under a microscope.

Mohs surgery is a highly specialized and precise treatment for skin cancer removal in which the cancerous tissue is removed in stages, one tissue layer at a time. It is an outpatient procedure, performed under local anesthesia, and is distinguished by a specific technique of tissue examination that is unique to Mohs surgery. Although other surgical specialists may check excision margins, this form of pathologic examination of the tissue is not the same as Mohs surgery.

It’s important to choose a fellowship-trained Mohs surgeon who is a member of the American College of Mohs Surgery, like Dr. Mendese, Dr. Nathan, and Dr. O’Connor. Mohs College surgeons have undergone at least 1 year of fellowship training beyond dermatology residency, which allows for additional experience in all of these specialized processes and techniques.

The term “micrographic” refers to the use of a microscope to examine tissue layers during the procedure. Once a tissue layer is removed, its edges are marked with colored dyes, and a map of the specimen is created. The tissue is then processed onto microscope slides by a Mohs histotechnician. These slides are carefully examined under the microscope by the Mohs surgeon so that any microscopic roots of cancer can be precisely identified and mapped.

If cancer cells are seen, an additional tissue layer is removed only in areas where the cancer is still present, leaving normal skin intact. This saves as much normal, healthy skin as possible.

Once the cancer has been removed, the Mohs surgeon will explain options for repair of the wound, including natural healing (granulation), stitching the wound together using a side-to-side closure, or using a skin flap or graft.

By using this precise process, we identify and ensure removal while persevering as much healthy tissue as possible. This leads to the smallest and most hidden scar possible. Our surgeons at Dermatology & Skin Health perform this outpatient procedure while the patient is under local anesthesia, removing cancerous tissue in stages, a single 1-2mm layer at a time.

This approach is particularly beneficial for areas where preserving tissue is crucial, such as the face, scalp, hands, or other sensitive places. By combining meticulous mapping and examination with the expertise of fellowship-trained and board-certified Mohs surgeons, this technique ensures both precision and care.

While dermatologists receive some surgical training/exposure during their residency training (the time spent just after medical school graduation), nothing can substitute for the intensity and refined techniques learned during a dedicated Mohs Fellowship.

An American College of Mohs Surgery (ACMS) Fellowship in Micrographic Dermatologic Surgery (Mohs) consists of 1 to 2 years of nothing but skin cancer surgery. This includes the removal (Mohs) as well as reconstruction (stitching) and learning everything there is to know about the latest and greatest surgical and non-surgical treatment of skin cancer.

There are a minimum of 500 surgical cases a Fellow must complete prior to graduation. In most cases, Fellows perform over 1,000 surgical cases before graduating. While many board-certified dermatologists have experience with Mohs surgery—some become board-certified in it—a Fellow who has completed post-residency training truly possesses the necessary skills and expertise.

We proudly perform your surgery as safely and effectively as possible. All of our Mohs surgeons at Dermatology & Skin Health are double board certified in dermatology as well as micrographic dermatologic surgery (Mohs); and have all completed fellowships prior to practicing. All of our surgeons are members of the American College of Mohs Surgery—the largest and most respected governing body specific to Mohs.

The Surgical Resource Center (SRC) has awarded our practice the Surgical Site of Excellence designation—a title held by only 2 practices in the US. Furthermore, the SRC also designated Dr. Mendese a Surgeon of Excellence. At Dermatology & Skin Health, you can rest assured you are receiving only top notch care for your skin cancer.

Yes. Following a biopsy, your skin cancer may no longer be visible. However, the surface lesion that was removed can represent the “tip of the iceberg.” More tumor cells may remain in the skin. These can continue to grow downward and outward, like the roots of a tree. These “roots” are not visible to the naked eye. If they are not removed, the tumor will likely reappear and require more extensive reconstructive surgery.

Tumors that are neglected can spread deeply into the skin and invade nearby structures. On rare occasions, these cancerous cells can metastasize to lymph nodes and other organs in the body.

Mohs surgery has the highest cure rate. It is appropriate for most skin cancers and especially suitable for skin cancer that has any of the following characteristics:

• Is in an area where it is important to preserve healthy tissue for maximum functional and cosmetic result
• Was treated previously and has come back
• Is located near scar tissue
• Is large
• Does not have clearly defined edges
• Is growing rapidly or uncontrollably
• Is of an aggressive subtype (i.e., sclerosing or infiltrating basal cell carcinoma )
• Develops in organ transplant or lymphoma patients

Please note: the above list is not exhaustive of all of the instances where Mohs surgery is the most appropriate option for your skin cancer.

Although Mohs surgery can take longer than other techniques to perform, advances in technology, such as automated staining of tissue samples, have made it quicker. While it is impossible to predict exactly what timeframe to expect for each Mohs surgery procedure, the entire procedure usually lasts 1 to 2 hours.

Rarely, clearing the tumor and reconstructing the defect can take the better part of a day. A consultation with the Mohs surgeon prior to your procedure will allow the surgeon to understand the unique qualities of your situation and enable him/her to more clearly estimate the extent of the timeframe for the surgery.

Yes, as will any treatment for skin cancer, Mohs micrographic surgery will leave a scar. But we work to hide it.

Mohs micrographic surgery preserves as much healthy skin as possible and maximizes options for repairing the surgical defect, once the tumor is completely removed. Once the Mohs surgeon has completely removed your skin cancer through Mohs surgery, reconstruction for optimizing the final functional and cosmetic result becomes the highest priority.

Generally, a post-surgical scar improves with time and can take up to a year or more to fully mature. As your surgical site heals, new blood vessels can appear and support the healing changes occurring underneath the skin. This can result in the reddish appearance of the scar. This change is temporary and will improve with time.

In addition, the normal healing process involves a period of skin contraction, which often peaks 4 to 6 weeks after the surgery. This may appear as a bumpiness or hardening of the scar. On the face, this change is nearly always temporary and the scar will soften and improve with time.

If you have a history of abnormal scarring, such as hypertrophic scars or keloids, or if there are problems with the healing of your scar, injections or other treatments may be used to optimize the cosmetic result. Your Mohs surgeon is available for you throughout the healing process to discuss any concerns that may arise.

The vast majority of patients don’t need anything more than a suture removal appointment. Some don’t even require that. However, if needed, at Dermatology & Skin Health, we offer a variety of laser treatments that can address redness or textural irregularities post-surgery. These are performed without a charge to the patient. We want you to have the best outcome possible and will see you as often as necessary to make the patient (and us) happy.

Mohs surgery boasts the highest cure rate of any skin cancer treatment, with a success rate of up to 99% for basal cell carcinoma and squamous cell carcinoma when treated early. The meticulous, layer-by-layer approach ensures the removal of all cancerous cells while preserving healthy tissue, resulting in this unparalleled effectiveness.

When you choose Mohs surgery at Dermatology & Skin Health, you’re placing your care in the hands of fellowship-trained and board-certified Mohs surgeons who bring extensive experience and dedication to every procedure. Each center is an accredited Surgical Center of Excellence and led by Dr. Mendese—a Surgeon of Excellence. You can trust our team to deliver the highest standard of care, ensuring both your health and peace of mind.

We perform Mohs surgery in precise stages, with surgeons carefully examining each layer of tissue to ensure all cancer cells get removed.

• During the procedure: The process begins with local anesthesia to numb the treatment area. Your surgeon will remove a thin layer of tissue, which they then analyze under a microscope. If your surgeon finds cancer cells, they will remove additional layers only from the affected area. They repeat this process until they achieve clear margins. Between stages, you can rest comfortably, listen to music or watch TV.
• After the procedure: Once we fully remove the cancer, your surgeon will discuss wound repair options, which may include stitching the wound, a skin graft, or natural healing. Most patients can resume light activities the same day, although some swelling or tenderness is common. Avoid strenuous exercise or any activity stressing the surgical area for 1–2 weeks, following your surgeon’s recommendations.

Before any treatment starts, our team will make sure you’re properly educated on the entire process. We will provide detailed pre and post-care instructions, including how to care for the wound, minimize scarring, and optimize healing. We’ll be with you through the entire process, ensuring you feel supported and reassured throughout your Mohs surgery treatment and recovery.

The term “Mohs” refers to Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, who developed this surgical technique in the 1930s. The technique has undergone many refinements and has come to be known as “Mohs micrographic surgery” or simply “Mohs surgery” in honor of Dr. Mohs.