Mohs Micrographic 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

How successful is the treatment of skin cancer?

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.
What is Mohs Micrographic Surgery?

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:

1. healing by spontaneous granulation;
2. closing the wound or part of the wound with stitches;
3. using a skin graft;
4. 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.
How do I prepare for the day of surgery?

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.
What happens the day of 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.
What can I expect after the surgery is completed?

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.
Will I develop more skin cancers?

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.