Mohs Surgery

Dr Binstock completed a fellowship in Mohs Surgery at UCSF, is a fellow of the American College of Mohs Surgery, and has performed approximately 8,000 Mohs Surgical procedures.

Approximately 60 years ago, Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, developed a technique known as chemosurgery to treat skin cancers. This procedure provides patients with an excellent chance for cure. The method is time-consuming and requires highly specialized training and personnel; most medical centers and few private offices in the United States are equipped to offer such treatment. The large number of patients who have been cured clearly demonstrates that Mohs surgery is a highly successful method of treatment for skin cancer.

This section attempts to answer some of the questions you may have as a patient concerning our procedure for treating skin cancer. Should you have further questions, please do not hesitate to contact us at any time.

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What is skin cancer?

Cancer is 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. The names refer to the cells of the skin giving origin to the cancer.

How does skin cancer start, and how does it grow?

Skin cancer begins in the uppermost layer of the skin and grows inward, 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 actually may be only the tip of the iceberg.

Is it dangerous?

The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Both types enlarge locally from their 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 paths of growth. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are therefore 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, melanomas originate in moles which have been present for many years.

What causes skin cancer?

The causes of skin cancer, like other forms of cancer, are 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 on the arms (the most sun-exposed parts of the body). Fair-skinned people develop skin cancer more frequently than dark-skinned people. Skin cancer, unlike cancer of other organs, is rare in Blacks. Cancers of the skin are more common in the southern United States. Skin cancer also tends to be hereditary and occurs very frequently in certain ethnic groups, especially those with fair complexions such as Northern Italians and Celtics (especially Irish). Other possible factors contributing to the development of skin cancer include X-rays, trauma, and certain chemicals.

How may skin cancer be treated?

There are several methods of treating skin cancer, all highly successful in the majority of patients. These methods include excision (surgical removal) and suturing (sewing), curettage and electrodesiccation (scraping and burning with an electric needle), radiotherapy (X-ray), cryosurgery (freezing), topical chemotherapy (chemical destruction), and Mohs Surgery (microscopical controlled excision). The method chosen depends on the location of the cancer, its size, and previous therapies.

What is Mohs chemosurgery?

The term Mohs chemosurgery is derived from “Mohs,” the name of its originator, and the words “chemical” and “surgery.” It is a highly specialized procedure for the total removal of skin cancers. Originally, the procedure involved the application of a chemical on the skin. Subsequently, the procedure was revised and refined, eliminating the need for the chemical fixative while maintaining the microscopic controlled excision. Today, Mohs chemosurgery is more aptly described by the term Mohs surgery or microscopic controlled excision.

How is Mohs surgery performed?

There are three separate steps to the Mohs surgery technique: 1) curettage of the visible part of the skin cancer; 2) surgical removal (or excision) to a certain depth of that tissue; 3) examination of this excised tissue under the microscope. Before this tissue is examined, it is marked with colored 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 found, the procedure is repeated, but only in the area of the remaining cancer.

How long does it take?

Total removal of a skin cancer, which may involve several surgical sessions of a few hours duration, 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.

How effective is Mohs Surgery in the treatment of skin cancer?

Using the Mohs surgery technique, the percentage of success is very high, often 97–99%, even if other forms of treatment have failed. Therefore, with this technique, an excellent chance of cure is achieved.

What are the advantages of Mohs Surgery?

Using microscopic examination, the Mohs surgeon can pinpoint areas involving cancer and selectively remove tissues only from 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 50–70% chance of success in curing skin cancers that have had previously unsuccessful treatment.

Will the surgery leave a scar?

Yes. Any form of therapy will leave a scar; however, the Mohs surgery procedure tends to minimize this as much as possible.

Will my insurance reimburse me for Mohs surgery?

Most health insurance policies cover the cost of Mohs surgery; your coverage will depend on your particular policy’s deductible and co-pay. Each policy is different. Please check with our office manager if you have any questions regarding costs and insurance forms.

What happens at the preoperative (consultation) visit?

The preoperative visit gives Dr. Binstock an opportunity to examine your skin cancer, take a pertinent history, and determine whether the technique of Mohs surgery is the most suitable way of treating your skin cancer. Also, it gives you the opportunity to learn about the procedure.

Every skin cancer is different, and because of the high demand for Mohs surgery, careful scheduling is necessary. A suitable date for surgery that is mutually acceptable will be arranged.

When a patient has been referred to us, usually the biopsy (removal of a piece of tissue) has already been performed, and we have the pathology report stating the type of skin cancer present. If we do not have this information, we usually perform the biopsy at the initial visit. This simple procedure takes only a few minutes. Since all skin cancers are not alike, we need to know exactly what type you have before we can decide how best to proceed.

All patients are photographed before any treatment (usually at the initial visit), as well as immediately after surgery, and after healing. These photographs become part of your medical record and may be used for teaching purposes.

Will I need to be hospitalized?

Whenever possible, the surgery is performed as an outpatient procedure, but very rarely 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.

How should I prepare myself for Mohs surgery?

Try to get a good night’s rest and eat a light breakfast. If you are taking any medication, take it as usual unless we direct otherwise.

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.

Should someone come with me the day of surgery?

Yes. It may be pleasant to have company while you are sitting in the waiting room, and it is recommended that you have someone available to drive you home.

Does it hurt?

Dr. Binstock will use a local anesthetic, usually Xylocaine®, to numb the skin around the skin cancer. Be sure to inform us if you experience anything more than slight discomfort.

How long does the surgery take?

Appointments for surgery are usually scheduled early in the day. This allows us to continue throughout the entire day if necessary. The first step is for Dr. Binstock to surgically remove a thin layer of skin involved with the cancer. After this tissue has been carefully removed, bleeding is stopped with a cauterizing machine which generates heat. Before you leave the surgical suite, the nurse will dress your wound and the removed tissue will be sent to the laboratory for microscopic examination.

It usually takes about an hour to prepare the slide(s), although sometimes it may take somewhat longer.

If examination of the slide(s) reveals that your tissue still contains cancer cells, the procedure will be repeated as soon as possible. The average number of surgical sessions and microscopic examinations is two or three, so most patients are finished by mid-day. If you must stay longer, have a light lunch, and please avoid alcoholic beverages.

It is seldom necessary to have a patient return the following day for additional surgery.

Will I have pain after surgery?

Most patients do not complain of pain. If you are uncomfortable, we recommend taking two tablets of Tylenol® or Datril® every four hours. Avoid aspirin-containing compounds (such as Anacin® or Bufferin®), and nonsteriodal anti-inflammatory  agents such as Advil®, Motrin®, Anaprox®, etc., as these may produce bleeding.

What about bleeding after the surgery?

Rarely does bleeding occur following surgery. If this should happen, lie down and place steady, firm pressure over the bandage as close as possible to the area that is oozing blood. Apply the pressure continuously for twenty minutes (timed). Do not lift the bandage to check on the bleeding. If the bleeding persists after twenty minutes of steady pressure, notify our office or go to the nearest hospital emergency room.

What are other possible complications?

All wounds develop a small, surrounding halo of redness which disappears gradually. Severe itching with extensive redness may indicate a reaction to the adhesive tape. You should call our office if this develops.

Swelling is common following Mohs surgery, particularly when it is performed around the eyes. All wounds show a moderate amount of swelling. Usually this is not a problem.

What is the next step after Mohs surgery has been completed?

When we have determined that the skin cancer has been completely removed, a decision is made on what to do about 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 cover the wound with a skin graft or flap. We will recommend which of these choices will be best for your individual case.

How should I take care of a wound closed with sutures or covered by a skin graft?

If we close the wound with sutures or place a graft, keep the wound clean and dry until your next visit. If a foul-smelling fluid oozes from the wound, call our office immediately. This may mean that the wound has become infected and an antibiotic may be necessary.

If the wound is allowed to heal by itself, what is the procedure?

When the wound is allowed to heal by itself (or granulate in), it usually does so in four to eight weeks. The dressing must be changed every day until healing is complete. All wounds normally drain, and dressings are changed daily to rid the wound of such drainage. Our nurses will instruct you on how to change the dressing.

What happens after the wound has 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 a 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 (such as cold air). This sensitivity lessens with time, and the redness gradually fades. However, if you are having a lot of discomfort, try to avoid extremes of temperature.

Patients frequently experience itching after their wounds have healed because the new skin that covers the wound does not contain as many oil glands as previously existed. Plain petroleum jelly will help relieve the itching.

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 physicians for yearly visits.

Studies have shown that once you develop a skin cancer, there is a 50% likelihood that you will develop another in the next five years. We recommend that you be seen at least once a year for the rest of your life by your dermatologist so that he/she may determine whether you have developed any new skin cancers. Also, should you notice any suspicious areas on your skin, it is best to check with your referring physician to see if a biopsy is indicated.

Should there be a recurrence of the skin cancer after Mohs surgery, it should 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.

My skin cancer has been treated several times. Will I ever be cured?

A frequent reason for being sent to us for Mohs surgery is that other forms of treatment have failed. This does not mean that you are cancer-prone or 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 surgery uses complete systematic microscopic control to search out the roots of cancer, it cures almost all patients—even those in whom skin cancer has persisted in spite of several other treatments.

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 a sun protection factor of 20 or greater to all exposed areas, including the tops of ears. It is best to apply the sunscreen about fifteen minutes before going outdoors. Be sure to reapply 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 can enjoy a normal lifestyle—if you take precautions. Remember, an ounce of prevention is worth a pound of cure.