Approximately 30 years ago, Dr. Frederic Mohs developed a technique to remove skin cancers. The large number of cases which have been cured clearly demonstrates that Mohs' Surgery is a highly successful method of treatment for skin cancer.
2. WHAT IS SKIN CANCER?
The most common types are basal cell carcinoma and squamous cell carcinoma. Both types enlarge from the point where they first occur and usually do not spread (metastasize) to distant parts of the body. If not completely removed both can invade and destroy adjacent structures such as the eye or nose. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are therefore more easily cured. If left untreated, skin cancer will form a non-healing ulcer which gradually enlarges.
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. Sometimes melanomas arise in moles which have been present for many years.
3. WHAT CAUSES SKIN CANCER?
The cause of skin cancer, like other forms of cancer, is 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 arms (the most often sun exposed parts of the body). Fair skinned people develop skin cancer more frequently
than dark skinned people.
Skin cancer also tends to be seen more often in certain ethnic groups, especially those with fair complexions such as English, Irish, Scottish, and Scandinavians. Thus, the tendency to develop skin cancer is inherited along with your type of complexion.
4. HOW DOES SKIN CANCER START? HOW DOES IT GROW?
Skin cancer begins in the uppermost layer of the skin and invades downward with roots and to the sides on the surface of the skin. Unfortunately, these extensions cannot be directly visualized. What is apparent to the naked eye on the surface of the skin may
actually be only the "tip of the iceberg".
5. 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), radiation (x-rays), cryosurgery (freezing), and Mohs' Surgery (microscopically controlled excision). Which
method I use depends on several factors, such as the location of the cancer, the size of the cancer and previous treatments of the cancer.
6. WHAT TYPES OF CANCERS ARE TREATED BY MOHS' SURGERY?
A. Cancers on or around the nose, ears or eyes which have not been treated before.
B. Cancers which have been treated but have recurred.
C. Cancers which have a scar-like appearance and feel.
D. Large cancers.
E. Cancers with hard to judge borders.
7. HOW IS MOHS' SURGERY PERFORMED?
Until about 1975 a chemical fixative was applied to the cancer prior to removal. The procedure was then referred to as Mohs' "Chemosurgery". Advances in technique and methods over the past ten years have eliminated the need for this chemical fixative. The term "Chemosurgery" is therefore no longer appropriate.
Mohs' Surgery is performed in an office setting under local anesthesia. Mild sedation may be given if necessary. The skin that appears to be involved with cancer is then removed and the edges of the skin are color coded for later identification and orientation under the microscope.
After preparation in the laboratory, the entire periphery and undersurface of the specimen is examined microscopically to detect any residual cancer. If cancerous cells remain more skin is removed but only from the area where cancer remains and this tissue is examined in the same way. The process is repeated until the cancer has been completely removed. Usually 2-3 layers are removed in a typical case.
8. HOW LONG DOES IT TAKE?
The average case lasts 2-4 hours. Most of the time you will spend waiting while I prepare and examine the tissue. Bring reading material or something else to occupy your time on the day you schedule surgery.
9. HOW EFFECTIVE IS MOHS' SURGERY IN THE TREATMENT OF CANCER?
Using the Mohs' technique, the success rate is 96 to 99, even if other forms of treatments have failed. Thus, with this technique, an excellent chance of cure is achieved. However, no one can guarantee a 100 chance of cure.
10. WHAT ARE THE ADVANTAGES OF MOHS' SURGERY?
The Mohs' Surgeon can pinpoint with the microscope the areas where there is cancer and selectively remove tissues only from those areas. In this way, the skin cancer is traced out to its roots with no guesswork involved. This results in: a) the removal of as little normal tissue as possible; b) the highest chance of curing the patient. Studies have indicated that other forms of therapy have only a 50 to 75 chance of success in curing skin cancers that have had previous treatment that has failed. The success rate for these recurrent cancers is 96 - 99 by the Mohs' technique.
11. WHAT HAPPENS AT THE PREOPERATIVE CONSULTATION VISIT?
The preoperative visit gives me 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 cancer. Also, it gives you an opportunity to learn about the
Each skin cancer is different and careful scheduling is necessary. A suitable date for surgery that is mutually acceptable will be arranged.
When a patient has been referred to me, sometimes the biopsy (removal of a piece of tissue) has been performed, and I have the pathology report that states what type of skin cancer is present. If I do not have this information I will perform a biopsy at the
initial visit. Because not all skin cancers are alike, I need to know exactly what type you have before I can decide how best to proceed.
12. HOW SHOULD I PREPARE MYSELF FOR MOHS' SURGERY?
Try to get a good night's rest, eat a light breakfast and get to the office on time. If you are taking any medication, take it as usual unless I direct otherwise. Avoid aspirin (or medications that contain aspirin) for at least two weeks prior to surgery. Aspirin tends to prolong bleeding during the operation.
13. WILL I HAVE PAIN AFTER THE SURGERY?
Most patients do not complain of significant discom-fort. However, pain is an individual phenomenon and if you are uncomfortable I recommend taking two tablets of Tylenol (acetaminophen) every four hours. Avoid aspirin containing compounds (such as Anacin or Bufferin) as these may produce bleeding. Alcohol also may predispose to bleeding.
14. WHAT ABOUT BLEEDING AFTER SURGERY?
Very occasionally there is continued bleeding follow-ing surgery. If this occurs, lie down, remove all of the bandages except the layer closest to the skin, and place steady, firm pressure over the wound as close as possible to the area of bleeding. Apply the pressure continuously for 15 minutes. Do not lift the bandage to check on the bleeding. If the bleeding persists after 15 minutes of pressure, notify my office or go to the emergency room.
15. WHAT IS THE NEXT STEP AFTER MOHS' SURGERY?
When I have determined that the skin cancer has been completely removed, a decision will be made about managing the wound. Usually there are four choices:
A. Close the wound with stitches;
B. Let the wound heal by itself;
C. Cover the wound with a skin graft or a flap;
D. Referral to a second surgeon (head & neck, ophthalmic, or plastic) for repair.
16. WHAT ARE THE MAJOR ADVANTAGES OF MOHS' SURGERY?
A. It assures complete removal of the skin cancer while preserving as much normal skin as possible.
B. It is done as an office procedure avoiding operating room or hospital fees.
C. It is safe, reliable and has a significantly higher cure rate than any other available technique, even when dealing with the most difficult cases.
17. HOW OFTEN MUST I RETURN FOR FOLLOW-UP VISITS?
A follow-up visit or period of observation at intervals for at least five years is essential, either with me or your referring physician. After the wound has healed patients return at three-four months, then six month intervals for five years. There are two reasons why this is important:
1. If there is a recurrence of the skin cancer after Mobs' Surgery, it may 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.
2. Studies have shown that once you develop a skin cancer, there is a high risk that you will develop others in the years to come. I recommend that you be seen at least once every 6 months during the first five years to determine whether you have developed any new skin cancers. Also, you should watch for an open sore which does not heal and bleeds easily. If you notice any suspicious area, it is best to check with me or your referring doctor to see if a biopsy is indicated.