Mohs Micrographic Surgery

Mohs micrographic surgery is a minor surgical procedure and special method of removing skin cancers using local anesthesia (numbing). The majority of cases are performed right in the physician’s office. Mohs is a very precise, highly detailed technique whereby small layers of skin are removed and immediately examined under the microscope to make sure the skin cancer is completely removed. The procedure uses frozen sections of skin which are then stained with special dyes. The dyed frozen pieces of skin are further examined under the microscope and a tumor map is drawn by the Mohs surgeon. The freezing process allows an immediate examination of the entire tumor margin and tissue histology (microscopic examination of cells). If more cancer cells or “roots” are seen under the microscope, then another skin layer is removed and again examined. Each time that a skin level is removed, it is called a “level”. If no more cancer roots are seen, then it is called “clear” (no more tumor) and no additional levels are needed. By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with good preservation of normal skin. Once the cancer has been fully removed, the Mohs surgeon looks at the wound to determine the way to get the best wound repair and cosmetic result for you. Mohs is special because the entire edge and undersurface of each skin cancer layer is carefully examined under the microscope for the presence of very small cancer cells. With regular or traditional surgery only about 1 to 3% of the tumor margins are actually examined thereby increasing the chances that a small tumor root would be missed and left behind. Mohs allows for examination of 100% of the tumor margins thereby reducing the chance that tumor cells will be left behind. Mohs is usually scheduled only on certain days in the doctor’s office because of the required equipment, tissue stains (dye), Mohs technologists, and microscopes. Most of these procedures are generally performed with the patient waiting in the office for the tissue to be “read” or interpreted by the Mohs surgeon.

Mohs micrographic surgery is usually performed in an outpatient setting like a doctor’s office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

You are generally in the medical office for several hours( average 2-7 hours) on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctor’s careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their day’s schedule open to allow for adequate time to complete their Mohs.

Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or Ear , Nose and Throat ( ENT) surgeons who are trained and may also perform Mohs.

There is no current Board Certification for Mohs Surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery and the American Society for Mohs Surgery (ASMS). Both of these medical groups have specialty training and certification exams for their members. Members of The American College of Mohs Surgery usually have completed an additional 1 to 2 years of Mohs training. Members of the American Society for Mohs Surgery are also trained and required to actively participate in an annual quality control Mohs slide peer review.

Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove non-cancerous growths.

Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofirosarcoma protuberans, merkel cell tumor, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma and other cancerous tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.

No, Mohs is usually not for mole removal. It is primarily designed for removing skin cancers. Moles are usually removed by standard or traditional surgery.

You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health. Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort. Your physician can help you sort through the different treatments and assist in your shared decision making process. However, the right decision for you is always yours and your doctor’s to make.

Your Mohs surgeon needs to know of any other medical conditions that may affect your surgery or wound healing. You would want to make sure to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips , a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur. Your Mohs surgeon needs to know if you have had a history of “Staph” or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like Hibiclens ( Chlorhexidine) the night or morning before surgery to help reduce the number of bacteria on your skin. Patients need to also advise their surgeon of any drug allergies such as to anesthetics like lidocaine, xylocaine, epinephrine, or novacaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, Hepatitis, HIV/ AIDS, or pregnancy.

Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, ears, and genitals. It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have re-grown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

As with any surgery or procedure , Mohs is associated with some possible risks and complications. While it is overall a very safe and effective minor surgical treatment, there are some possible uncommon complications. Since a scar usually forms anytime you cut the skin, most patients understand and expect some type of a scar after skin cancer removal.

Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid ( raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, widened or sunken in( depressed) scar, wound opening ( dehiscence) and spitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and rarely death. Minor, serious, or life threatening reactions can occur with the use of anesthetics or with medications given before, after or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent. Overall, most patients tolerate the minor surgery very well without any complications.

Reconstruction is repairing or fixing the wound. Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometime an area may heal better by letting the wound heal in by itself naturally without stitches. Additional reconstruction options include using a skin graft, moving a flap of skin, and plastic surgery closure. Shared decision making is very important in this part and you are involved in how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound. The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

Yes, all human beings heal by permanent scar formation. In general, when you cut the skin, there will be some type of scar. Some people heal better than others. Some scars are more noticeable depending on the location and skin type. There are many options for treatment of surgical scars including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch removal appointment.

It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, prescription topical creams, plastic surgery, curettage and desiccation (scrape and burn), regular surgery, chemotherapy creams or injections, cryosurgery ( deep freezing), photodynamic therapy ( uses a type of light and a light activated chemical called a photosenzitizer).

Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

Mohs, like any surgical procedure, will result in additional procedure charges above the routine office visit fees. These surgical fees may range from one to two thousand dollars depending on the area, number of Mohs levels, and the type of closure or repair required. The more number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare. Commercial or non-Medicare insurances currently generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

You may decide to have regular surgery with a plastic surgeon instead of having Mohs. Alternatively, you may also choose a hybrid option where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you. If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

Your personal physician will let you know the pre-operative instructions specific for your condition. For many typical outpatient Mohs surgeries in a physician’s office, most patients are advised to eat a good breakfast on the day of surgery and take all of their regular daily medications. Patients are advised to wear comfortable casual clothes and bring a sweater or small blanket. In most cases, patients are usually able to drive after most procedures and do not necessarily need a driver unless they feel uncomfortable. Diabetic patients may need to be more cautious about maintaining good blood sugars and avoiding dangerous lows in their sugars from fasting. Since you will be in the office for several hours, you may want to bring some personal snacks, drinks, and reading or knitting material. Personal music headsets or Ipods may also provide relaxation and help pass time between Mohs levels. For surgery center or hospital based procedures requiring any type of sedation or general anesthesia, patients may be required to not eat or drink anything past midnight the night before surgery. Your plastic surgeon or anesthesiologist will advise you of specific instructions before surgery. Most patients continue all doctor prescribed medications including aspirin and any blood thinners unless specifically advised otherwise only by the primary physician, or plastic or Mohs surgeon. Patients with a significant history of stroke, heart attacks, or even chesp pain (angina) under a doctor’s care must discuss their medications with their doctor before making any changes. It is important to not discontinue blood thinners without a doctor’s specific instructions because of a potential greater risk of a heart attack and/or stroke. For otherwise healthy (non-cardiac and non-stroke patients) non-essential, non-medically prescribed, blood thinners such as Advil (ibuprofen), Motrin, Aspirin, Vitamin E, garlic supplements, Alka-seltzer, Peptobismol , other aspirin containing medications , etc. can be stopped at least 7-14 days before undergoing Mohs surgery to minimize bleeding and bruising.. These medications can thin your blood and make you more prone to bleed during and after surgery. Again, it is important to not discontinue or start any medication without a doctor’s specific instruction.

Smoking is discouraged for at least 1-2 weeks before surgery. Smoking can slow down wound healing and cause more wound infections. Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is generally helpful. Stitches (sutures) are usually removed at the surgeon’s office anywhere from 4-14 days from the date of surgery. Your physician will let you know what date to return for stitch removal.

Most patients are able to return to work or school the same day or next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for 7-21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

Most patient report no or minimal discomfort after surgery and require no pain medication. If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take Tylenol (Acetaminophen) or another pain reliever over the counter. Aspirin or Aspirin containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain. Your physician will let you know what pain medications are recommended for your specific condition.

It is generally required to check with your surgeon for their specific wound care instructions just after surgery. Often, you will be asked to go home and take it east for the rest of the day “couch potato day”. A few patients like to return to work and resume their work day after surgery. It may be advisable to avoid heavy lifting and exercise especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery. You will have usually have a bulky “pressure” dressing on the surgery area for 1 day. You may be asked to keep the area dry until 24 hours. Swimming pools, oceans, and jaccuzi’s are usually off limits while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide 2-3 times a day and applying an over the counter antibiotic ointment to the area.

Mild swelling is not uncommon the 1st day or two after surgery and can be lessened by use of an ice bag, ice cubes or chips in a small Ziplock baggie, or frozen peas in their bag. Leaving the dressing in place, ice use every 5-15 minutes every hour for the first 8-24 hours after surgery. Swelling is more common around for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area. The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to for ten to fifteen minutes to the site may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified of non-stopping bleeding. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding. Your surgeon will need to know if pain is increasing after 1-2 days after your surgery or you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeon’s office. The surgical area may need to be promptly checked for bleeding or infection. Limiting hot foods, hot drinks, andheavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas. Your physician will let you know their recommended wound care.

Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin colored tape strips called steristrips are available to minimize and help cover-up a visible wound. It is important to follow your own physician’s instructions for wound care.

There is a very low chance that your skin cancer will recur after Mohs surgery. Mohs cure rates have been reported as high as 96-99%. It is important to understand that no cancer treatment or surgery has a 100% cure rate. A skin cancer may recur or a new cancer may arise in the same or adjacent area even after Mohs or other surgery. Some skin cancers are more aggressive than others and need additional treatment and closer follow up. Skin cancers frequently need additional follow up and possible further treatment. Although Mohs surgery tends to have the highest cure rate compared to other treatments, Mohs may not be necessarily curative in advanced skin cancer ( rare cases) and may need one or more procedures such as radiation or further surgery to fully treat the lesion.

Good follow up appointments with your physician are very important, especially in the first few years after Mohs. Many patients are seen every 4-6 months after their diagnosis of a skin cancer. Self skin examinations monthly are good practice for patients with a history of skin cancer. Any changing or new growth should be promptly checked by your physician. More regular follow up appointments may be needed for those with more aggressive tumors or tumors in high risk areas. Your physician will recommend the proper follow up for your specific condition.

On average, most patients may only need 1 or 2 levels before clearing the tumor roots. Depending on the skin cancer type and location, a patient may need anywhere from 1 to 10 or more levels of Mohs to clear a tumor. There is no way to predict ahead of time how many levels your cancer will require for cure. The number of Mohs levels needed to completely remove the skin cancer depends on how big your cancer is and where the “roots” are. Mohs surgeons alway strive to remove your cancer in as few levels as possible. There is also very little way to predict beforehand how large a skin cancer is because often there are invisible portions “roots” which can be seen only with the help of a microscope. Sometimes, more than one surgical procedure may be required to remove very large or invasive tumors, cancers in small areas or difficult areas, or to obtain the best medical and cosmetic result.

There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to possible skin cancer. Use of sunscreen or other cover up on the scar is very helpful for at least 6 months after surgery to help minimize scarring. It is important to follow your own physician’s instructions for wound care and sun protection.

There are many good and effective ways to treat skin cancers. Options include local radiation (X-ray) treatments, curettage and desiccation “C&D” ( scrape and burn), cryosurgery (specialized deep freezing), photodynamic therapy using Levulan and laser and or blue light, regular surgical excision, plastic surgery treatment, interferon injections, laser removal and surgery, Mohs surgery, and several prescription creams including Aldara ( imiquimod) and Efudex ( flurouracil).

Mohs is named after its inventor Dr. Frederic Mohs who first described the technique in 1941. .