THE MOHS PROCEDURE
It's helpful to know what to expect before you undergo any surgical procedure. Because the Mohs surgery procedure for skin cancer removal is somewhat complex, it can be reassuring to become familiar with the treatment process ahead of time. Here, you can learn what to expect before, during, and after your procedure.
*Mohs surgery is the most effective treatment for most types of skin cancer.
Before Your Surgery
When you meet with Dr. Stephen Vance, certified surgeon by the American College of Mohs Surgery (ACMS) for a consultation, you determine together whether a Mohs surgical procedure is the best course of action for your cancer. Once you have set an appointment for surgery, you receive a detailed list of instructions to follow beforehand.
*Do not stop anti-coagulants unless directed by physician.
You may be asked to:
Temporarily stop the use of certain medications, including some over-the-counter pain relievers, supplements, and other medicines
Stop consuming certain foods or beverages a number of hours before your procedure
Clear a full day for your procedure, because it is difficult to predict how long it may take
Dr. Vance and his team will give you more information about these and other considerations before your surgery, and it's important to follow this advice as closely as you can to ensure a successful outcome.
Mohs Micrographic Surgery Video
Your Mohs Procedure
Surgeons usually perform Mohs skin cancer surgery as an outpatient procedure in the office, which has an on-site surgical suite and a laboratory for microscopic examination of tissue. Typically, surgery starts early in the morning and is completed the same day, depending on the extent of the tumor and the amount of reconstruction necessary.
You receive local anesthesia around the area of the tumor, so you are awake during the entire procedure. The use of local anesthesia versus general anesthesia provides numerous benefits, including preventing a lengthy recovery and possible side effects from general anesthesia. You are completely numb in the area of the surgery, though, so the procedure is comfortable.
After the area has been numbed, your Mohs surgeon removes the visible tumor, along with a thin layer of surrounding tissue. A technician then prepares this tissue and puts it on slides for your surgeon to examine under a microscope. If the surgeon sees evidence of cancer around the outer edges of the removed tissue, he or she takes another layer of tissue from the area where the cancer was detected. This ensures that only cancerous tissue is removed during the procedure, minimizing the loss of healthy tissue. Your surgeon repeats these steps until all samples are free of cancer. Although there are always exceptions to the rule, most tumors require 1 to 3 stages for complete removal.
To get a better picture of how this process takes place, please view Mohs Step-by-Step Process.
After Your Surgery
When your surgery is complete, your Mohs surgeon assesses the wound and discusses your options for ideal functional and cosmetic reconstruction. ACMS surgeons understand that a good cosmetic result is an important part of the recovery process, and that's why they work so hard to leave as little tissue damage as possible. If reconstruction is necessary, the Mohs surgeon usually repairs the area the same day as the tumor removal.
Learn more about Mohs surgery recovery and post-operative care.
In the vast majority of cases, the wound can be dealt with on the same day as the Mohs procedure. The anesthesia used will usually continue to be local anesthetic or sometimes supplemented with an oral sedative. In more difficult cases where it is necessary for complicated reconstructive procedures to be performed, it may be necessary to send the patient through a hospital or surgery center where general anesthetic or deep sedation is used.
There is a wide range of options in dealing with wounds created by Mohs surgery. These include:
"Granulation" - This is allowing the wound to heal on its own much as if a person who falls and scrapes his/her knee or elbow and treats it with local wound care of cleansing and applying topical ointment and bandages until it is allowed to heal.
Grafting - This may include harvesting of skin from another site on the body or a xenograft, which is processed porcine, which serves as a biologic dressing temporarily until the body can take over the healing much as in granulation.
Flap closure - This can involve very small sites up to massive sites and may be fairly simple and thin to multi-staged procedures which may include skin and muscle and cartilage as well.
Tissue expansion - Tissue expansion is the last option, which is not used frequently. It involves inserting an inflatable reservoir or balloon under the skin at the first procedure then inflating it until the body produces additional skin, which can then be manipulated to close the wound.
Postoperative care is usually straight forward involving cleansing the wound area and doing dressing changes. More complicated situations such as grafting usually involve a dressing, which is allowed to stay on the wound for a few days since it assists in immobilization of the graft so that the body can grow blood vessels into it to nourish it and allow it to take. The number of postoperative visits depend on how complicated the wound is and how much oversight is required. In some areas, it may be possible to place dissolving stitches, which require minimal if any care making the postoperative course less arduous for the patient.
Complications of surgery are typically standard and include blood loss. Infection is also a risk in approximately 4% to 6% of patients. Patients are not usually placed on antibiotics routinely unless they are considered at greater risk for infection, usually due to the location of the wound being near an orifice such as the mouth or ear canal, which has a higher number of bacteria. Scarring is a natural process of the body healing the wound. This is a lengthy progression, which incorporates multiple stages and types of collagen and actually takes many months even though the wound is closed. Instructions regarding optimal care of the wound postoperatively to minimize scarring are given to the patient. There may be tissue loss or loss of part of a flap or skin graft and these situations are handled on an individual basis. In most cases, the body will slough off the necrotic or dead tissue and heal the area again. Again, this will require additional care for the wound.
Some patients have a tumor, which invades the area of a nerve, therefore requiring interruption of the nerve and resulting in what is usually limited to loss of sensation in an area. There are, however, a few superficial motor nerves that go to muscles, which can be injured or removed in the course of surgery. Depending on the situation location, these may or not be repaired at a later date. In some patients due to scar tissue and damaged nerves, the patient can have chronic pain in the area. Fortunately, this is a very rare complication of surgery.
Revisions of the surgical site are not often required. They are usually done in 6 to 12 months after the original surgery allowing the wound to mature and soften as well as improve as time goes by. Initially the surgical site does not appear pretty, but it usually improves significantly and satisfactorily as time progresses.