Mohs Micrographic Surgery
What is Mohs micrographic surgery?
Mohs micrographic surgery has been proven to be the most effective technique for removing basal cell and squamous cell carcinomas (the two most common types of skin cancer) as well as some melanomas and other more unusual skin cancers. This technique was developed by Dr. Frederick Mohs in the 1930s.
The technique used in Mohs surgery results in the highest cure rate, as well as the best cosmetic result because it spares healthy tissue more than traditional methods. The technique is a systematic approach of removing the skin cancer and examining the tissue samples immediately. The samples are cut in a unique method with detailed mapping to examine the margins. Only the margins that are not clear need further excision, thus preserving as much healthy tissue as possible.
Mohs micrographic surgery results in a near perfect cure rate, which is superior to other approaches and spares healthy tissue resulting in better cosmetic results.* This technique is especially useful on areas of the skin that benefit from tissue sparing, head and neck, genital areas, hands and feet and on lesions that have reoccurred.* In addition, Mohs is done under local anesthesia in the comfort of the office as opposed to having to undergo general anesthesia in a hospital.
Fellowship-trained Mohs Surgeons, like Dr. Mendese, have completed rigorous Mohs-specific training after residency. During this time, fellows treat hundreds (if not thousands) of patients with Mohs under the direct supervision of a more senior surgeon over the course of a year or more. To find out the difference between fellowship-trained Mohs surgeons and others, please refer to the following link: www.skincancermohssurgery.org
Why is it called Mohs surgery? Is Mohs an acronym?
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.
What is Mohs surgery?
Dr. Mohs recognized that a 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 with the naked eye, but can be seen under a microscope.
Mohs surgery is a highly specialized and precise treatment for skin cancer in which the cancer 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.
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 the 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.
It’s important to choose a fellowship trained Mohs surgeon who is a member of the American College of Mohs Surgery, like Dr. Mendese. 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.
I don’t see anything after my biopsy; do I really need to be treated?
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 roots of a tree. These “roots” are not visible with the naked eye. If they are not removed, the tumor will likely reappear and require more extensive 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.
Why does my skin cancer need to have Mohs surgery?
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.
How long does the surgery take?
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 1-2 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 for 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.
Will Mohs surgery leave a scar?
Yes, as will any treatment for skin cancer, Mohs surgery will leave a scar. But we work to hide it.
Mohs 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 1 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 and 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.
Is Mohs surgery the most cost-effective treatment option?
Because of Mohs surgery’s high success rate, most patients require only a single surgery. This surgery usually includes the repair of the wound as well. Other methods might require additional surgeries and pathology readings in order to repair the wound and to treat the cancer if it is not completely removed. Each of these additional surgeries and pathology readings require separate fees, while a single Mohs surgery procedure includes all of these into one fee.
In summation, Mohs micrographic surgery is highly regarded as a remediation technique:
- Boasts the highest cure rate for skin cancer
- Assures that the smallest amount of normal skin is removed, maximizing the likelihood for preserving function and minimizing scar
- Minimizes risks with local anesthesia compared with general anesthesia
*Individual results may vary; not a guarantee.