Warren Skin Care Center

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Mohs Surgery

INTRODUCTION

In 1937, Dr. Fredrich Mohs, Professor of Surgery at the University of Wisconsin, and Nobel Prize in Medicine nominee, developed a technique for the surgical removal of skin cancers known as chemosurgery. This technique provides patients with the highest chance of cure for even complicated cancers. This method is time-consuming, requires highly specialized training and personnel.

This information pamphlet will attempt to answer some of the questions you may have as a patient concerning our procedure for the treatment of skin cancer. Should you have further questions, please do not hesitate to contact us.

The Micrographic Surgery Unit consists of several individuals who will serve you. In addition to Dr. Li, the team includes surgical assistants who are experienced in dealing with skin cancer patients and knowledgeable about and experienced in caring for any prob­lems which may arise. Another important member of our team are the technicians who quickly and precisely prepare the tissue for microscopic examination. Finally, the office secretaries and office manager round out the team.

(1) What is skin cancer? Cancer is a tissue which grows at an uncontrollable and unpredictable rate. There are three main forms of skin cancer; basal cell carcinoma, squamous cell carcinoma, and malignant melanoma. These names refer to the cells of the skin giving origin to the cancer.

(2) Is it dangerous? The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Both types enlarge locally from the point of origin and usually do not spread (metastasize) to distant parts of the body. If not completely re­moved, both types will frequently invade and destroy structures in their path of growth. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are, therefore, more easily cured. Malignant melanoma, on the other hand, may be life-threatening if not treated early. It usually appears as a brownish-black spot or bump on the skin which enlarges and sometimes bleeds. Occasionally, melanoma originate in moles which have been present for many years.

(3) What causes skin cancer? The cause of skin cancer, like other forms of cancer, is not completely known. Excessive exposure to sunlight is the single most important factor associated with the development of these skin cancers which appear most commonly on the face and arms (the most sun-exposed areas of the body). Fair-skinned people develop skin cancers more frequently than dark skinned people. Skin cancer, unlike cancer of other forms is rare in blacks. Cancer of the skin is common in the southern United States. Skin cancers also tend to be hereditary and occur frequently in certain ethnic groups, especially those with fair complexions, such as Northern Italians and people from Northern Europe. Other possible factors contributing to the development of skin cancer includes x-ray, trauma, and certain chemicals.

(4) How does skin cancer start? Skin cancer begins in the upper­most layer of the skin and grows downward forming roots and spreads horizontally, along the surface of the skin. Unfortunately, these extensions cannot be directly visualized. Therefore, what is apparent to the naked eye on the surface of the skin may only be the “tip of the iceberg”.

(5) How is it removed? There are three separate steps in the removal of skin cancer by Mohs’ Micrographic Surgery: (1) surgical removal of the visible portion of the skin cancer with excision or curettage; (2) surgical removal of a thin layer of tissue surrounding the cancer; and (3) examination of the excised tissue under the microscope. By thorough examination of the edges and bottom portion of the removed tissue, the physician is able to trace out and exactly locate any additional areas for cancer left in the patient. Before this tissue is examined it is marked with color dyes to distinguish top from bottom and right from left. By doing this, we are able to pinpoint the exact location of any remaining tumor during the microscopic examination. If more cancer is present, the procedure is repeated but only the area of remaining cancer is removed.

(6) How long does it take? Total removal of a skin cancer, which may involve several surgical sessions with waiting periods between, is usually completed in one day. After the surgery, a decision is made as to the best way to manage the wound created by the surgery. This will be discussed later.

(7) How effective is Mohs’ Micrographic Surgery in the treat­ment of skin cancer? Using the micrographic surgical technique, the percentage of success is very high, often 97 to 99 percent for basal cell carcinomas even if other forms of treatment have failed. Therefore, with this technique, an excellent chance of cure is achieved; however, no one can guarantee a 100 percent cure.

(8)What are the advantages of Mohs’ Micrographic Surgery? Using microscopic examination, the micrographic surgeon can pinpoint areas involved with cancer and selectively remove only those areas. In this way, the skin cancer is traced out to its roots. This results in the removal of as little normal tissue as possible and the highest chance of cure. Other forms of therapy frequently have only a 50% to 70% chance of success in curing skin cancers that have been previously unsuccessfully treated.

(9) Will the surgery leave a scar? Yes. Any form of therapy will leave a scar; however, the Mohs’ Micrographic Surgery procedure tends to minimize this as much as possible. This is because Mohs’ Micrographic Surgeons try to remove only those tissues involved with cancer and preserve all the normal tissue possible. We make every effort to obtain an optimal cosmetic result for the patient and may work in conjunction with a plastic surgeon if necessary.

(10) How much does the surgery cost and will my insurance pay? Micrographic Surgery is outpatient surgery just as if it were performed in a hospital outpatient clinic. Medicare accepts almost all our total charge and will reimburse you 80% of their accepted charge. If you have a second insurance policy or co-insurance this should pay the major portion of the remaining bill. For those who do not yet have Medicare, the amount that your policy will pay toward the cost of this surgery varies with the type of policy that covers you. If you should have any questions concerning this, you should discuss this with Dr. Li. The surgery is fairly expensive since it requires us to maintain our own surgical suite and lab. There will be no separate charge, however, for the use of the surgical suite or the lab, which would be customary if the surgery were to be carried out in an outpatient surgery clinic or hospital. Please check with Dr. Li or one of his assistants if you have any questions regarding cost or insurance forms. We will be glad to help file your insurance and Medicare claims; however, the patient will be responsible for any balance not covered by insurance.

(11) What happens at the pre-operative visit? The pre-operative visit gives Dr. Li the opportunity to examine your skin cancer, take any pertinent history, and determine whether the technique of surgery is the most suitable way of treating your skin cancer. Also, it gives you an opportunity to learn about the procedure. Every skin cancer is different, and because of the high demand for Mohs’ Micrographic Surgery, careful scheduling is necessary. A suitable date for surgery that is mutually acceptable will be arranged. Patients referred to us from out of town may be scheduled for surgery at the time of their initial visit. When the patient has been referred to us, usually a biopsy (removal of a piece of tissue) has been performed and we have a pathology report stating the type of skin cancer present. if we do not have this information, we usually perform a biopsy at the initial visit. Since all skin cancers are not alike, we need to know exactly what type you have before we can decide how to best proceed. Almost all patients will be photo­graphed before treatment as well as immediately after surgery and again after healing. These photographs become part of your medical record and may be used for teaching purposes.

(12) Will I need to be hospitalized? Whenever possible, the surgery is performed as an outpatient procedure in our office. Occasionally we require that the patient stay in the hospital. We will inform you if we feel it would be best for you to be hospitalized at the time of your initial visit.

(13) How should I prepare myself for Mohs’ Micrographic Surgery? Try to get a good nights rest and eat a good breakfast. if you are taking any medications, take them as usual unless we direct otherwise. We do request, however, that you do not take aspirin or aspirin or ibuprofen -containing products such as Advil, Motrin, Aleve or Plavix for one week prior to the surgery since this thins the blood and causes more bleeding. If you are on blood thinners (coumadin), please notify us as soon as possible. If you have recent knee or hip replacement or mechanic heart valves or other heart valves disease, please contact Dr. Li or your heart doctor for possible prophylactic antibiotics treatment.  It is a good idea to bring a book or magazine with you on the day of surgery. The procedure may take a full day, much of which you will spend in the waiting room. Please, no alcoholic beverages since these cause blood vessels to dilate and aggravate problems with bleeding.

(14) How long does the surgery take? Each step (or stage) of the surgical procedure takes about 15 to 30 minutes. Following the surgery, it usually takes over one hour for the slides to be prepared for microscopic examination. Several surgical stages and micro­scopic examinations may be required.

(15) Should someone come with me on the day of surgery? It depends

It may be pleasant to have company while you are sitting in the waiting room and it is recommended that you have someone drive you home if the surgery interfere your vision, but most of the time you can drive yourself. We ask that you limit the number of people accompanying you to two persons because of limited space in our waiting room. No children please.

(16) Does it hurt? The surgeon will use a local anesthetic, usually xylocaine (Lidocaine) to numb the skin around the cancer. Be sure to inform us if you experience anything more than slight discomfort.

(17) What happens on the day of surgery? Appointments for surgery are usually scheduled early in the day. This allows us to continue through the entire day if necessary. After you arrive for surgery, an assistant will take you to the surgery suite and prepare the area to be removed for surgery. If you have any questions, this is a good time to ask them. Next, Dr. Li or his assistant will come in, anesthetize the area and then remove a thin layer of skin involved with the cancer. After this tissue has been carefully removed, the bleeding will be stopped with a cauterizing machine which generates some heat. Before you leave the surgical suite, the assistant will dress your wound. The removed tissue will be sent to the laboratory for examination. it usually takes 15 to 30 minutes to anesthetize the involved area and to remove the tissue. It will take approximately 1 1/2 to 2 hours to prepare the tissue for microscopic examination. While you are waiting, you are free to leave the area for refresh­ments. If examination of the tissue removed reveals that your tissue still contains cancer cells in the surgical site, the procedure will be repeated as soon as possible. Several surgical excisions and microscopic examinations may be performed in one day. Seldom is it necessary for the patient to return the following day for additional surgery.

(18) How many surgical sessions are there? The average number of surgical sessions for most skin cancers is two to three, so most patients are finished by mid-afternoon. When we have determined that the skin cancer has been completely removed, a decision is made on what to do with the wound created by the surgery. Usually there are three choices: (1) to close the wound with stitches; (2) to let the wound heal by itself; (3) to close the wound by skin graft. We will recommend which of these choices will be best for your individual case.

(19) What happens after the wound is healed? You may expe­rience a sensation of tightness (or drawing) as the wound heals, but this is normal. After several months, you will feel this less and less. Frequently, tumors involve nerves and it may take up to one year or even two, before feeling returns to normal or near normal. Some­times the area stays numb permanently. Only time will tell. The new skin that grows over the wound contains many more blood vessels than the skin that was removed. This results in a red scar and the area may be sensitive to temperature changes. This sensitivity improves with time and the redness gradually fades. However, if you are having a lot of discomfort, try to avoid extremes of temperatures. Patients frequently experience itching after their wound has healed because the new skin that covers the wound does not contain as many oil glands as previously existed. Plain petroleum jelly or other skin moisturizer will help relieve the itching.

(20) Once the wound has healed, how often must I return for a follow up? A follow up period of observation for at least five years is essential after the wound has healed. Our practice is to have patients return to their referring dermatologist for bi-annual visits. Patients initially seen in our office will return here in 4 months then every 3-6 months depends upon what kind of skin cancer you have. Should there be any recurrence of the skin cancer after the micrographic surgery, it may be detected at once and treated. Experience has shown that if there is a recurrence, it usually will be within the first year following surgery. Studies have shown that once you develop a skin cancer, there is a possibility that you will develop others in the years ahead. We recommend that you be seen at least once a year for the rest of your life by your dermatologist so that he may determine whether you have developed any new skin cancers. Also, should you yourself notice any suspicious areas on your skin, it is best to check with your referring physician to see if a biopsy is indicated.

(21) My skin cancer has been treated several times. Will I ever be cured? A frequent reason for being sent to us for micrographic surgery is that other forms of treatment have failed. This does not mean that you have a hopeless case. It merely means that the methods used to treat you in the past were not effective enough to destroy all of your skin cancer cells. Because Mohs Micrographic Surgery used complete systematic microscopic control to search out the roots of the cancer, it cures almost all patients - even those in whom skin cancer has persisted in spite of several other treat­ments.

(22) Later on must I avoid the sun? No, not entirely. We do not think that sunshine will be harmful to you as long as you provide yourself with adequate protection, avoid burning, and use discre­tion. As mentioned earlier, sunlight probably is the main contribut­ing factor in the development of skin cancer, and patients who have developed one skin cancer often will develop more at a later time. Therefore, in the future, when you go into the sun, we recommend that you liberally apply a sunscreen with protection factor of 50 to all exposed areas, including the tops of the ears. It is best to apply the sunscreen about 20 minutes before going outdoors. Be sure to reapply it liberally after swimming or exercising since most sun­screens wash off with water or perspiration. In addition to a sunscreen, you may wish to wear a broad-brimmed hat and utilize clothing to further protect yourself from the sun. Yes, you may lead a normal life style if you take precautions. Remember, an ounce of prevention is worth a pound of cure.

SUMMARY

Mohs’ Micrographic Surgery provides the greatest chance for cure for even the most complicated of skin cancers. Using this surgical technique, we are able to spare as much normal skin as possible so that we have the maximum amount of tissue for good healing. Since this procedure is carried out under local anesthesia, the risk to the patient is quite small, even in those who have other complicated illnesses. The wound healing from this surgery is usually excellent but if further cosmetic surgery is necessary, we are able to work closely with several excellent plastic surgeons in the area.

If you should have any questions or problems do not hesitate to contact Dr. Li at any time at 908-387-1001