MOHS SURGERY
An
information brochure prepared by Surgeon:
John K. Geisse, M.D.
How successful
is the treatment of skin cancer?
What is Mohs Micrographic
Surgery?
How do I prepare for
the day of surgery?
What happens the day of
surgery?
What can I
expect after the surgery is completed?
Will I develop more skin
cancers?
Mohs Surgery Photographs
Initial treatment of skin cancers has a success rate
greater than 90%. Methods commonly employed to treat skin cancer include:
excision (surgical removal and stitching), curettage and
electrodesiccation (scraping and burning with an electric needle),
cryosurgery (freezing), and radiation therapy ("deep" X-ray). Patients may
have had one or more of these methods of treatment before coming for Mohs
Micrographic Surgery.
The success rate in treating a recurrent skin cancer (ie.
one that persists after conventional treatment) can be as low as 50%. The
cure rate for Mohs Micrographic Surgery, even in treating recurrent
lesions, is about 98%.
Mohs Micrographic Surgery (discussed in detail below)
is very time consuming, requires a highly-trained team of medical
personnel, and is available at relatively few locations in the country.
Mohs Micrographic Surgery is reserved for recurrent skin cancers or for
primary skin cancers that are difficult to treat usually including the
central face.
In the early 1940's, Dr. Frederick Mohs, Professor of
Surgery at the University of Wisconsin, developed a form of treatment for
skin cancers he called chemosurgery. The word "chemosurgery" is derived
from the words "chemical" and "surgery."
In the last 30 years, the procedure has been refined
and improved upon so that most cases are done using fresh tissue omitting
the chemical paste Dr. Mohs used. The procedure is now called Mohs
Micrographic Surgery.
Dr. Geisse has had sub-specialty surgical training in
the technique and is a Fellow of the American College of Mohs Micrographic
Surgery and Cutaneous Oncology. The nurse is an important part of the team
who will help answer your questions, respond to your anxieties, assist in
surgery, and instruct you in dressings and wound care after the surgery is
performed. A technician, whom you may not even meet, performs the
essential task of preparing the tissue slides which are examined under a
microscope by the physician.
The surgery is performed as follows: the skin is
treated with a local anesthetic so there is no pain; the tumor is scraped
using a semi-sharp instrument called a curette; a thin piece of tissue is
then removed surgically around the scraped skin and divided into pieces
that will fit on a microscope slide; the edges are marked with colored
dyes; a map or diagram of the tissue removed is made; and the tissue is
frozen by the technician. A pressure dressing is then applied and the
patient is asked to wait while the slides are being processed. Dr. Geisse
will then examine the slides under the microscope and be able to tell if
any tumor is still present. If cancer cells remain, he is able to exactly
locate them based upon his map. Another layer of tissue is then removed
and the procedure is repeated until Dr. Geisse is satisfied that the
entire base and sides of the wound have no cancer cells remaining. As
well as ensuring total removal of the cancer, this process preserves as
much normal, surrounding skin as possible. The removal of each layer
of tissue takes approximately 1-2 hours. Only 20-30 minutes is spent in
the actual surgical procedure, the remaining time being required for slide
preparation and interpretation. It usually takes removal of 1-3 layers of
tissue (stages) to complete the surgery. Therefore, by beginning in the
morning, Mohs micrographic surgery is generally finished in one day.
Sometimes, however, a tumor may be extensive enough to necessitate
continuing surgery a second day.
At the end of Mohs Micrographic Surgery, you will be
left with a surgical wound. This wound will be dealt with in one of
several ways. The possibilities explained below include:
- healing by spontaneous granulation;
- closing the wound or part of the wound with
stitches;
- using a skin graft;
- using a skin flap;
Healing by spontaneous granulation involves letting the
wound heal by itself. This offers a good chance to observe the wound as it
heals after removal of a difficult tumor. Experience has taught us that
there are certain areas of the body where nature will heal a wound as
nicely as any further surgical procedure. There are also times when a
wound will be left to heal knowing that if the resultant scar is
unacceptable, some form of reconstruction can be performed at a later
date.
Closing the wound with stitches is often performed on a
small lesion. This involves some adjustment of the wound and sewing the
skin edges together. This procedure speeds healing and can offer a good
cosmetic result. For example, the scar can be hidden in a wrinkle line.
Skin grafts involve covering a surgery site with skin
from another area of the body. There are two types of skin grafts. The
first is called a "split thickness graft." This is a thin shave of skin,
usually taken from the thigh, which is used to cover a surgical wound.
This can either be a permanent coverage or temporary coverage before
another cosmetic procedure is done at a later date. The second graft type
is the "full thickness graft." This graft provides a thicker layer of skin
to achieve better results. In this instance, skin is usually removed from
behind the ear or around the collar bone (the donor site) and stitched to
cover the wound. The donor site is then sutured together to provide a good
cosmetic result.
Skin flaps involve movement of adjacent, healthy tissue
to cover a surgical site. Where practical, they are chosen because of the
excellent cosmetic match of nearby skin.
If your Mohs Micrographic Surgery is extensive or a
functional impairment results, we may recommend you visit one of several
consultant physicians. If you have been sent to us by another physician
skilled in skin closures (for example, a plastic surgeon), he/she will
take care of you after your cancer has been removed.
In summary, by microscopically pinpointing areas
involved with cancer and selectively removing these tissues, the Mohs
surgeon can successfully remove your skin cancer with the best cure rate
and the least loss of normal tissue. A smaller wound also offers you the
possibility of a better final cosmetic result. Although an attempt will be
made to minimize the scar, you will be left with a scar of some kind.
The best preparation for Mohs Micrographic Surgery is a
good night's rest followed by breakfast. In most cases, the surgery will
be completed on an outpatient basis. Because you can expect to be here for
most of the day, it is wise to bring a book or magazine to read. Also,
because the day may prove to be quite tiring, it is advisable to have
someone accompany you on the day of surgery to provide companionship and
transportation home.
Your referring physician may request that you have a
pre-operative visit to evaluate the need for Mohs Micrographic Surgery and
meet Dr. Geisse. At this visit, the technique will be discussed in detail
and your questions answered. If you are coming a great distance and/or are
being referred by a physician familiar with this technique, you may be
referred directly for Mohs Micrographic Surgery without a pre-operative
visit. If this is the case and you have never been a patient in Vallejo
before, you should plan to arrive 10-15 minutes before your scheduled
appointment in order to complete some initial patient forms.
The cost of Mohs Micrographic Surgery is borne by most
insurance carriers. Please be prepared to give insurance information to
our billing personnel and bring with you any forms which may need
processing. We can counsel you concerning your insurance coverage at the
time of surgery. Some insurance companies require authorization prior to
surgery.
Your appointment has purposely been scheduled early in
the day. Upon your arrival, you should check in at the registration
window. When the surgical suite becomes available, you will be escorted by
our surgical nurse to that area of the clinic. If you have not had a
consultation visit, she will go through the procedure with you and answer
any questions you may have. Dr. Geisse will also be available to answer
questions. After this, the Mohs stages will be taken.
After the first stage, a pressure dressing will be
placed over your surgical wound and you will be free to leave the surgical
suite. On the average, it takes an hour for the slides to be prepared and
studied. During this time, you may wait in the waiting room, read a book
or magazine, or take a walk around the complex. There is a cafeteria
located at Sutter Solano Medical Center across the street.
Most Mohs surgery cases are completed in 1-3 stages.
Each stage involves the removal and microscopic examination of your skin
for cancer. Therefore, the majority of cases are finished during one day.
Once we are sure that we have totally removed your skin cancer, we will
discuss our recommendations for dealing with your surgical wound with you.
Pain. Most people are concerned about pain. You
may experience remarkably little discomfort after your surgery. Due to its
potential to cause bleeding, we request that you do not take aspirin, but
use Tylenol or acetaminophen. You will be provided with Vicodin or
Darvocet, codeine-like compounds with acetaminophen for the first few
days.
Bleeding. A small number of patients will
experience some bleeding post-operatively. This bleeding can usually be
controlled by the use of pressure. You should take a gauze pad and apply
constant pressure over the bleeding point for 15 minutes; do not lift up
or relieve the pressure at all during that period of time. If bleeding
persists after continued pressure for 15 minutes, repeat the pressure for
another 15 minutes. If this fails, call Dr. Geisse or visit a local
Emergency Room. If necessary, Dr. Geisse can be reached 24 hours a day. It
is advisable not to drink alcohol the first post-operative night, as this
may stimulate bleeding.
Complications. Some minor complications may
occur after Mohs surgery. A small red area may develop surrounding your
wound. This is normal and does not necessarily indicate infection.
However, if this redness does not subside in days or the wound begins to
drain pus, or becomes painful you should notify Dr. Geisse immediately.
Itching and redness around the wound, especially in areas where adhesive
tape has been applied, are not uncommon. When this occurs, ask your
druggist for a non-allergenic tape and tell us on your return visit.
Swelling and bruising are very common following Mohs surgery, particularly
when it is performed around the eyes. This usually subsides within 4-5
days after surgery and may be decreased by the use of an ice pack in the
first 48 hours. At times, the area surrounding your operative site will be
numb to the touch. This area of anesthesia (numbness) may persist for
several months or longer. In some instances, it may be permanent. If this
occurs, please discuss it with Dr. Geisse at your follow-up visit.
Although every effort will be made to offer the best
possible cosmetic result, you will be left with a scar. The scar can be
minimized by the proper care of your wound. Some scars and flap surgery
often require a second minor procedure in 6-8 weeks for optimal results.
We will discuss wound care in detail with you and give you a Wound Care
Informational Sheet which will explicitly outline how to take care of
whatever type of wound you have.
After having one skin cancer, statistics say that you
have a 50% chance of developing a second. There are precautions that can
be taken to prevent further skin cancers. You should use a sunscreen
(suntan lotion), applying it at least 30 minutes before exposure to
sunlight. The sunscreens are now labeled as to strength; the higher
numbers are more protective. We would recommend that you use a SPF #15 or
higher sunscreen. Despite manufacturer's claims, we recommend that you
re-apply sunscreen after swimming. A wide-brimmed hat, long-sleeved shirt,
and other protective clothing are also appropriate. Avoidance of excessive
sunshine is recommended especially between the hours of 10 AM - 2 PM..
You should have your skin checked very closely by your
referring physician at 6-month intervals. This is not only to check the
surgical site as it is healing, but to check for the development of
additional skin cancers. Our policy is for us to follow the majority of
our patients until the wound has healed and then they can continue to be
followed by their referring physician. Some patients who come great
distances will be followed post operatively by their referring physician.
We recommend 6-month follow-up visits for 2 years, then yearly. Of course,
any areas of your skin that change, fail to heal, or just concern you
should be brought to the attention of your referring physician or Dr.
Geisse immediately.
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Female with Basal Cell Carcinoma on the Nose
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