Mohs Micrographic Surgery

1
Mohs Micrographic Surgery

• A surgical method I perform in the office to
  remove skin cancer.
• Offering
• The highest possible chance of cure
• Maximum preservation of normal tissue

2
Mohs Micrographic Surgery

• Is named after Dr. Frederick Mohs.
• I studied with Dr. Mohs in Madison, Wisconsin to
  learn this technique.
• I was head of the Mohs Unit at OHSU for ten
  years.
• I have done this procedure on thousands skin
  cancers since 1978.

3
Mohs Micrographic Surgery

• Many skin cancers have invisible roots that
  extend into the normal appearing surrounding
  skin.
• If your doctor could tell how big the skin cancer
  was by looking at it, you wouldnt need Mohs
  surgery.
• Mohs surgery is a technique that allows those
  roots to be followed.

4
Other Treatment Methods

• Simple surgical excision (cut it out and stitch
  it up)
• Not so simple excision (plastic surgery) often
  performed in a hospital with some ability to
  check margins
• Curettage and electrodessiccation (scrape and
  cauterize)
• Radiation therapy
• Cryotherapy (freezing with liquid nitrogen)

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Which Cancer Is Likely To Have Roots(and need
Mohs Surgery)?

• Around the nose, eyes, lips, ears, temple scalp
• Recurrent cancers
• Aggressive appearance under the microscope
• Blurry margins
• Large cancers

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Mohs Micrographic Surgery

• Is used for the treatment of
• Basal Cell skin cancer (carcinoma)
• Squamous Cell skin cancer (carcinoma)
• Malignant Melanoma
• Other rare forms of skin cancer

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Basal Cell Carcinoma

• The most common type of skin cancer
• It is very slow growing and very rarely ever
  leads to death
• It does not metastasize (spread elsewhere)
• If left alone it can, however, eat away a nose, a
  lip, an ear or you can lose an eye from it.
• This would usually require many years

8
Squamous Cell Carcinoma

• The second most common type of skin cancer
• Responsible for 8-10,000 deaths annually in the
  United States
• In sun exposed areas, usually grows slowly but
  some grow more quickly
• The lip and ear are more dangerous spots

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Mohs Micrographic Surgery

• We do this here in the office usually on a
  Wednesday or Thursday.
• A local anesthetic is used to thoroughly numb the
  area.
• We dont do surgery unless you are numb!

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Mohs Micrographic Surgery

• Once numb, the soft part of the cancer is scraped
  away.

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Mohs Micrographic Surgery

• A thin layer of tissue (about 2-3mm thick) is
  then surgically removed from around and under the
  area.
• Green, black, blue and red dyes are added so that
  later, under the microscope, the doctor can tell
  top from bottom, left from right.
• A diagram is drawn showing the color codes.

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Mohs Micrographic Surgery

• The area is bandaged.
• You are free to wait in the waiting room.
• Try a cup of coffee or a pastry next door at the
  Milky Way Café.
• Initial results are usually back within 30-45
  minutes

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Mohs Micrographic Surgery

• The tissue is
• Frozen
• Sliced into thin layers
• Placed on glass slides
• Stained
• The doctor is then called to examine the slides
  under the microscope.

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Mohs Micrographic Surgery

• The doctor then looks at the slides and marks the
  location of any remaining cancer in red pencil on
  his diagram.

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Mohs Micrographic Surgery

• You return to the surgery room and instead of
  removing more tissue all the way around and under
  the wound, I remove more just from the place or
  places that are still positive.
• You are bandaged and wait again

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Mohs Micrographic Surgery

• When the slides are ready, I then examine them
  and once again mark the area or areas where
  cancer remains.
• You come back in and, once again, more tissue is
  removed just from those areas.

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Mohs Micrographic Surgery

• The process can go all day longwhich would be
  unusual.
• Or
• You can finish before lunchtimewhich would be
  more likely
• It all depends on the cancer and how far it
  extends into the normal appearing tissue.

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Mohs Micrographic Surgery

• When finished
• I can tell you, as well as anyone can tell you
  that all the cancer is gone. (This is the method
  that offers the highest possible chance of cure.
  Ask the doctor about your chances for
  recurrence.)
• We havent removed any more tissue than was
  necessary to remove the cancer.
• There is an ugly hole where the cancer used to
  be. (Thats what I would call it, if it were on
  me.)

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The Wound

• The final size, shape and depth of the hole is
  determined by the roots of the cancer.

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What do we do with the ugly hole?

• It can be allowed to heal in by itself or it can
  be repaired with plastic surgery techniques.
• We decide which plastic surgery method to use
  after we see the final wound.

21
Plastic Surgery Repair

• Sometimes, depending on size and location, the
  wound can be sewed up in a straight line.
• Sometimes a skin graft is necessary. (Borrowing
  skin from elsewhere and sewing in a patch)
• A skin flap is sometimes the best way. (Using and
  rearranging the skin next to the wound, while
  maintaining its blood supply)
• The doctor will discuss options with you.

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The Risks of Surgery

• These are the risks of any minor surgery
• Bleeding
• Infection
• Scar
• The risks related to the specific location of the
  tumor
• The risks related to your specific health problems

23
Blood Thinners to Avoid

• For two weeks before surgery, avoid
• Aspirin (or anything with aspirin in it)
• Vitamin E
• Gingko Biloba
• Ginseng
• Feverfew
• For two days before surgery
• Ibuprofen (Motrin, Advil) and other arthritis
  drugs
• Ephedra

24
Wound Care

• Wound care is different depending on whether you
• Have stitches
• Dont have stitches
• You will be given detailed written instructions.

25
If You Have Stitches

• The bandage is kept clean and dry until we remove
  the stitches, 5-7 days for wounds on the face.
  (This usually means you cant shampoo in the
  shower. You can shower from the neck down and
  possibly do your hair backwards in the sink or at
  the beauty parlor.)
• To decrease any black eye, we often recommend
  that you go home, sit up in a chair and hold an
  ice pack on the area on and off (mostly on) until
  bedtime that night.
• No heavy bending or lifting for 2-3 days.
• Avoid aerobic exercise for two weeks.

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No Stitches

• Cleanse the wound twice daily. We suggest
  moistening a cotton-tipped applicator with 0.9
  saline solution (Easily found as contact lens
  solution) and gently rubbing (not rolling) the
  wound.
• Cut out a circle of a non-stick wound dressing.
  (Telfa, Release, or the like)
• Cover it with Vaseline and apply with paper
  tape.
• Its OK to get the wound wet in the shower
• Exercise is fine

27
Follow-Up

• After healing is complete, you need to be
  checked
• Every three months the first year
• Every six months the second year
• Yearly until five years have passed

28
Follow-Up

• Required mainly for three reasons
• To check for recurrence of the cancer
• This is unlikely but still possible.
• To work on prevention
• Sun protection
• Treatment of pre-cancerous spots
• To detect any new skin cancer at an earlier stage
• Getting a skin cancer gives you a 50 chance of
  growing another one in the next 3-5 years.

29
Questions

• Dont hesitate to ask about anything you dont
  understand.
• Or even something you do understand.