Mohs micrographic surgery is a safe and highly effective technique whereby skin cancers are removed under complete microscopic control. The procedure is named after Dr. Frederic Mohs who developed this specialized technique in the 1930’s. In Mohs surgery, a thin layer of skin is removed around the visible cancer. Detailed maps are then drawn of the area, and 100% of the tissue margin is examined under the microscope to be sure that all of the cancer and its roots are gone. If any cancer remains, the exact area of involvement is sampled, and the entire process is repeated until the cancer is totally removed.
The two most common types of skin cancer, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are rarely life threatening. Compared with BCC, SCC has an increased risk to spread to other parts of the body. Fortunately, distant spread is uncommon when the cancer is treated early. Both types of tumors will continue to grow locally and destroy normal tissue. The third most common type of skin cancer, melanoma, can be life threatening if treated late. BCC and SCC lesions do not become melanomas.
By using the mapping technique and complete microscopic control, the Mohs surgeon can pinpoint areas involved with cancer that are otherwise invisible to the naked eye. Benefits include: 1) the highest possibility for curing the cancer and 2) the ability to save as much normal skin as possible. In contrast, standard surgery techniques look at less than 1% of the margins, providing only an estimate of whether the margins are clear. Also, with standard surgery the slides are not examined the same day, allowing the chance of finding a positive margin at an outside pathology lab and having to perform surgery at a later time to clear the margin.
Using Mohs surgery, the percentage of cure is more than 98% for most skin cancers, and more than 95% when other previous forms of treatment have failed. Non-surgical methods of treatment offer cure rates of around 88% for untreated cancers.
WHAT TO EXPECT THE DAY OF SURGERY
Surgery begins either early in the morning or early in the afternoon and is performed on an outpatient basis. Our staff will escort you into an exam room where Dr. D’Souza will discuss your case and further explain the procedure. A local anesthetic is injected into the skin to numb the area to be treated so you are awake during the procedure. You may experience some discomfort during the initial needle stick but this should only last a few seconds as the numbing is almost immediate – you should not experience significant pain during the surgery. Once the area is numb, the visible cancer is removed as well as a thin layer of tissue around the cancer. A temporary dressing is applied and then you are escorted to our waiting area. This part of the procedure only takes a few minutes. The tissue is then mapped by Dr. D’Souza and taken to our laboratory where it is color coded, processed, and examined under the microscope. This part of the procedure takes 1-2 hours while you wait in the patient lounge. If any additional affected area is identified, the precise location of the tumor is mapped, and the process is repeated until all of the cancer is removed. The number of stages or layers required varies for each patient and depends on the size and depth of the tumor. Please do not be discouraged if your cancer is not removed in one step, and instead remember that we are trying to preserve as much skin as possible. On average, half of tumors are removed in 1 stage, and the great majority of tumors are removed in 3 stages or less. Since one cannot predict in advance the number of stages necessary to fully remove the tumor, you should plan on spending the whole day with us (at least 4-6 hours). Please do not make other plans or appointments for your surgery date.
Once the area is cancer free, Dr. D’Souza will discuss the options of wound healing and surgical repair. This generally includes reconstructive surgery with stitches, occasionally involving a skin graft or flap, or allowing the area to heal on its own. If surgical repair is deemed appropriate, it is generally done in our office on the same day as the Mohs surgery. Following the repair, a dressing is applied and you will be given instructions on wound care and dressing changes.
PREPARING FOR SURGERY
Should I eat before surgery?
Because the procedure is performed under local anesthesia, you should eat a normal healthy breakfast and/or lunch the day of surgery. The rare exception is if you are scheduled to have your reconstruction done by another physician after Mohs surgery has been completed – in this case you will follow the instructions from the other physician’s office.
Should I take my regular medications before surgery?
Please take your daily prescription medications prior to surgery, especially blood pressure medications. Also bring with you a list of your medications, including non-prescription drugs. If you take antibiotics prior to dental or other surgical procedures due to artificial joints or heart valves, please mention this once you arrive for your appointment as we may give you antibiotics prior to the surgery.
Patients on blood thinner medications on the recommendation of a physician should continue taking them as directed. While stopping these medications may decrease risks of surgery (bleeding, bruising, etc.), doing so may increase your risk of stroke, heart attack, or blood clots – a more serious event. If you stop a blood thinner at your own preference, please also arrange a plan under for restarting after surgery is complete.
Patients on warfarin (Coumadin) should have their INR checked 1 week prior to surgery. Please notify us if your INR is greater than 3.0.
Should I avoid alcohol?
Alcohol will promote bleeding. We ask that you avoid alcoholic beverages 24 hours before and after your surgery.
Should I avoid smoking?
Smoking can impair wound healing by diminishing blood supply at your surgery site. We ask that you discontinue smoking 2 days before surgery and for 1 week after surgery. If you cannot discontinue entirely, cutting your daily use to less than half of normal is highly recommended.
Should I bring someone with me?
It is highly recommended that you make arrangements for someone to drive you to and from our office the day of surgery. This person may stay with you during the waiting period to keep you company between layers. Additionally, if someone other than you will be performing post-op wound care, the nurse can give this person direct instructions and demonstrate wound care.
Is there anything else I should bring with me?
You may want to bring reading material, playing cards, needlework, etc., to occupy your time while waiting for the microscope slides to be processed and examined. You may bring a cell phone to use quietly in the patient lounge, but please turn it off when in the surgical suite. We also recommend bringing a lunch with you. We can refrigerate your lunch when you arrive. Your companion may also bring you a snack or lunch since you are asked not to leave the patient lounge of our office. In addition, we have some snacks for our patients in the lounge if needed.
What should I wear?
We ask that you wear comfortable clothes. If your surgery is on an area covered by clothing, please wear clothes that are easy to remove. You may want to bring a sweater as our office is kept cool for the laboratory equipment needed for this procedure; alternatively we also have blankets that you may use. Please avoid wearing make-up, perfume, nail polish, and jewelry if these are near the location of your surgery.
If you have any problems at home after surgery, please do not hesitate to call our office. We will be glad to answer any questions. Instructions for wound care will be given to you at the end of your day.
Will I have pain after surgery?
The surgical site may be sore for several days after surgery. If there is any discomfort, acetaminophen (Tylenol) is usually adequate for relief. Avoid taking aspirin or ibuprofen-containing medications as they may cause bleeding.
Will I have bruising after surgery?
Bruising and swelling are common after surgery and may last for several days. This may not peak until 48 hours after surgery. We do not recommend planning your surgery date around an engagement where your physical appearance is important.
Will my activity be limited after surgery?
Activities, including exercise or heavy lifting, will be restricted for at least 2 weeks. If your work requires significant physical exertion, you may consider taking a few days off following the surgery. Avoid any long trips within the first few days following surgery in the rare event you develop any complications. The more activity you participate in after surgery, the more likely you will experience complications such as bleeding or a less cosmetically appealing scar.
Will the surgery leave a scar?
All forms of surgery result in a permanent visible scar. Scarring is minimized because the Mohs technique removes as little tissue as possible. The size of the scar depends on the size of the tumor and is often difficult to predict prior to surgery. Anticipate many stitches that extend outside the area where the cancer is located in order to have a superior final cosmetic outcome.
Will I need to come back?
Follow-up visits largely depend on the type of repair or sutures used to close your surgical wound. Periodic visits to your referring physician at least once a year are advisable to monitor for new skin cancers or signs of recurrence from previous procedures. Statistics show that a patient with skin cancer has a higher chance of developing another one, so follow-up skin exams are very important.
How can I protect myself from developing more skin cancers?
Sun protection is extremely important to minimize further damage to your skin and the risk for development of additional skin cancers. Here are some general recommendations:
1) Regularly and liberally apply a broad-spectrum sunscreen (SPF 30 or greater with UVA and UVB coverage) on a daily basis. Reapply every 2 hours during prolonged sun exposure, more frequently if you’re sweating or in water.
2) Cover up with protective clothing, wide-brimmed hats, beach umbrellas, etc., even on a cloudy day.
3) Avoid the sun at its most intense hours from 10am to 4pm if possible.
INSURANCE AND REFERRAL INFORMATION
We participate with most insurance plans. We will submit all claims to your insurance company. Expenses not covered include cosmetic procedures, deductibles, co-insurance, co-pay amounts and occasionally office visits. These fees will be collected at the time of service. Payments may be made by cash, check, or credit card.
Please check with your insurance company if you have any questions about coverage or preauthorization. If prior authorization is required, please contact your insurance company before surgery. It is important you tell them the following code information so that your referral is correct. You are having Mohs surgery (code 17311) for skin cancer (diagnosis code C44.*) and it will be performed in the office.
We would not want anyone to be denied medical care because of an inability to pay. If you have difficulties understanding or paying our bill, we encourage you to discuss your problem with our billing office at (866) 346-5033.
DIRECTIONS AND PARKING
Forest Dermatology and Mohs Surgery is located 1.8 miles south of I-40 (exit 50), on US-25 (Hendersonville Road). Our building is on the west side of the street; there is a light at the intersection / main driveway. Parking and the main entrance are in the back, and our Mohs Surgery suite is on the top floor.