Surgical Dermatology

The term “Mohs” refers to Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, who developed this surgical technique in the 1930s. The technique has undergone many refinements and has come to be known as “Mohs micrographic surgery” or simply “Mohs surgery” in honor of Dr. Mohs.

Dr. Mohs recognized that a skin cancer often resembles the “tip of the iceberg” with more tumor cells growing downward and outward into the skin like the roots of a tree. These “roots” are not visible with the naked eye, but can be seen under a microscope.

Mohs surgery is a highly specialized and precise treatment for skin cancer in which the cancer is removed in stages, one tissue layer at a time. It is an outpatient procedure, performed under local anesthesia, and is distinguished by a specific technique of tissue examination that is unique to Mohs surgery. Although other surgical specialists may check excision margins, this form of pathologic examination of the tissue is not the same as Mohs surgery.

Once a tissue layer is removed, its edges are marked with colored dyes, and a map of the specimen is created. The tissue is then processed onto microscope slides by a Mohs histotechnician. These slides are carefully examined under the microscope by the Mohs surgeon so that any microscopic roots of the cancer can be precisely identified and mapped. If cancer cells are seen, an additional tissue layer is removed only in areas where the cancer is still present, leaving normal skin intact. This saves as much normal, healthy skin as
possible.

Once the cancer has been removed, the Mohs surgeon will explain options for repair of the wound, including natural healing (granulation), stitching the wound together using a side-to-side closure, or using a skin flap or graft.

It’s important to choose a fellowship trained Mohs surgeon who is a member of the American College of Mohs Surgery. Mohs College surgeons have undergone at least 1 year of fellowship training beyond dermatology residency, which allows for additional experience in all of these specialized processes and techniques.

Yes. Following a biopsy, your skin cancer may no longer be visible. However, the surface lesion that was removed can represent the “tip of the iceberg.” More tumor cells may remain in the skin. These can continue to grow downward and outward, like roots of a tree. These “roots” are not visible with the naked eye. If they are not removed, the tumor will likely reappear and require more extensive surgery.

Tumors that are neglected can spread deeply into the skin and invade nearby structures. On rare occasions, these cancerous cells can metastasize to lymph nodes and other organs in the body.

Mohs surgery has the highest cure rate. It is appropriate for most skin cancers and especially suitable for skin cancer that:

• Is in an area where it is important to preserve healthy tissue for maximum functional and cosmetic result.
• Was treated previously and has come back.
• Is located near scar tissue.
• Is large.
• Does not have clearly defined edges.
• Is growing rapidly or uncontrollably.
• Is of an aggressive subtype (i.e., sclerosing or infiltrating basal cell carcinoma).
• Develops in organ transplant or lymphoma patients.

Please note: the above list is not exhaustive of all of the instances where Mohs surgery is the most appropriate option for your skin cancer.

Although Mohs surgery can take longer than other techniques to perform, advances in technology, such as automated staining of tissue samples, have made it quicker. While it is impossible to predict exactly what timeframe to expect for each Mohs surgery procedure, the entire procedure usually lasts several hours. Rarely, clearing the tumor and reconstructing the defect can take the better part of a day. A consultation with the Mohs surgeon prior to your procedure will allow for the surgeon to understand the unique qualities of your situation and enable him/her to more clearly estimate the extent of the timeframe for the surgery.

Yes. As will any treatment for skin cancer, Mohs surgery will leave a scar.

Mohs surgery preserves as much healthy skin as possible and maximizes options for repairing the surgical defect, once the tumor is completely removed. Once the Mohs surgeon has completely removed your skin cancer through Mohs surgery, reconstruction for optimizing the final functional and cosmetic result becomes the highest priority. Generally, a post-surgical scar improves with time and can take up to 1 year or more to fully mature. As your surgical site heals, new blood vessels can appear and support the healing changes occurring underneath the skin. This can result in the reddish appearance of the scar. This change is temporary and will
improve with time.

In addition, the normal healing process involves a period of skin contraction, which often peaks 4 to 6 weeks after the surgery. This may appear as a bumpiness or hardening of the scar. On the face, this change is nearly always temporary and the scar will soften and improve with time. If you have a history of abnormal scarring, such as hypertrophic scars or keloids, or if there are problems with the healing of your scar, injections or other treatments may be used to optimize the cosmetic result. Your Mohs surgeon is available for you
throughout the healing process to discuss any concerns that may arise.

When assessing the cost-effectiveness of Mohs surgery there are several factors to consider. Because of the number of personnel involved as well as the advanced technology required, the initial procedure is often more costly than other treatment methods. However, because of the procedure’s high success rate, most patients require only a single surgery. This surgery usually includes the repair of the
wound as well. While other methods might initially be less expensive than Mohs surgery, additional surgeries and pathology readings are required to repair the wound and to treat the cancer if it is not completely removed. Each of these additional surgeries and pathology readings will require separate fees, while a single Mohs surgery procedure includes all of these into one fee.

Anyone can get skin cancer, even those who have skin of color. Most people who get skin cancer, however, have lighter skin. People who are more likely to get skin cancer:

• Excessive time spent in the sun
• Use tanning beds or sun lamps
• Resided in an area that gets intense sunlight, such as Florida, the Caribbean, or northern Australia.

Any length of exposure, even if it occurred years ago or was short, increases your risk.

There are also some general characteristics which may increase a person’s risk for getting skin cancer, which include:

• A person’s skin type and the moles on one’s skin
• Family history of skin cancer
• Medical history
• Exposure to chemicals
• Tobacco

The most common warning sign of skin cancer is a change to your skin. And the most common change is something growing on your skin. This growth can appear on the skin in many ways.

To diagnose skin cancer, a dermatologist looks at the skin. A dermatologist will carefully examine growths, moles, and dry patches.

To get a better look, a dermatologist may use a device called a dermatoscope. The device shines light on the skin. It magnifies the skin. This helps the dermatologist to see pigment and structures in the skin.

If a dermatologist finds something that looks like skin cancer, the dermatologist will take a sample of all or part of the suspicious skin. and the sampled skin will be sent to a lab where it can be examined under a microscope. A biopsy should not cause anxiety. The discomfort and risks are minimal.

SPF means “Sun Protection Factor.” It is a measure of how well the sunscreen protects you from harmful UV rays from the sun. Sunscreen must be re-applied every two to three hours, even if it has a high SPF number. Adults and children should always wear at least SPF 15.

To lower the chance of skin cancer, adults and children should always wear at least SPF 15.

Recent research says that yes, tanning beds can cause cancer. The World Health Organization strongly urges all people to avoid using tanning beds, especially those under the age of 18.

There are different types of skin cancer. Each type is named after which type of cell it begins in. The three most common types of skin cancer are melanoma, basal cell carcinoma, and squamous cell carcinoma.

Only a doctor can tell if you have skin cancer. Be sure to talk to your doctor if you notice any unusual moles, bumps, or red patches, or if you notice a change in any moles you already have. It may be a good idea to perform a monthly self skin check. Talk to your doctor if you notice any new moles, bumps or rough patches that are unusual, or if you notice a change in any you already had. Things to look for include: changes in any moles, bumps, or rough patches, moles with a dark color (blue, black, purple, green, etc), moles that are not the same color or shade throughout, moles with irregular/wavy borders, moles that are asymmetrical (one side looks different than the other side), moles that are bigger around than the eraser on the top of a pencil, or spots that itch or bleed.

If a family member had skin cancer, you may have a higher chance of getting it. Some things, such as skin type, environment, and lifestyle are similar among family members.

Yes. Studies show that people who have one skin cancer are at greater risk of developing another skin cancer. Perform regular skin self- examinations, and protect your skin every day. Be sure to keep all appointments with your dermatologist, and make an immediate appointment if you notice anything changing, itching, or bleeding on your skin.

Yes. People of all skin colors can get BCC, although it is much more common in light skinned people.

Daily sun protection is an important part of skin cancer prevention. The following are some of The Skin Cancer Foundation’s list of prevention tips:

• Seek the shade, especially between 10 AM and 4 PM.
• Do not let your skin burn.
• Avoid tanning and never use UV tanning beds.
• Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses.
• Use a broad spectrum (UVA/UVB) sunscreen with an SPF of 15 or higher (most dermatologist recommend 30 or higher with zinc) every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30 or higher (again, most dermatologist recommend a higher SPF, of 50 or higher if planning on being outside).
• Apply 1 ounce (2 tablespoons, or 1 shot glass) of sunscreen to your entire body 30 minutes before going outside. Reapply every two hours or immediately after swimming or excessive sweating.

Yes. Studies show that people who have one skin cancer are at greater risk of developing another skin cancer. Perform regular skin self- examinations, and protect your skin every day. Be sure to keep all appointments with your dermatologist, and make an immediate appointment if you notice anything changing. itching, or bleeding on your skin.

Melanoma is the most deadly type of skin cancer. It can take many shapes and appearances. Melanoma is usually a dark color like brown, blue, or black. Other signs to look for include: irregular borders, asymmetry (one half looks different than the other half), and size – melanomas are usually large (bigger than a pencil eraser)