Mohs surgery is appropriate for many individuals with nonmelanoma skin cancers, such as basal cell carcinoma and squamous cell carcinoma. The level of precision associated with Mohs surgery maximizes the preservation of healthy tissue, making it especially appealing for the treatment of skin cancers in functionally and cosmetically sensitive locations, such as the face, scalp, neck, hands, and shins, and feet. In other less cosmetically and functionally sensitive areas of the body, it can be used to treat skin cancers that are larger, have previously been treated but recurred, do not have clearly defined edges, or display aggressive features under the microscope. Official Appropriate Use Criteria have been developed that help determine which skin cancers are most appropriate for treatment with Mohs surgery.

Mohs surgery typically involves five steps:

1. Anesthesia
Mohs surgery is performed using local anesthesia, which involves less risk than general anesthesia. At the beginning of the procedure, the area of interest is cleaned, then numbed with a mixture of lidocaine and epinephrine. While there may be some slight stinging or burning associated with the injection itself, the area around the injection quickly numbs, making the rest of the surgery painless.

2. Tissue Removal
The skin cancer is first debulked, allowing the physician to explore how deep the cancer penetrates beneath the skin. A thin layer of the surrounding tissue is then removed and a dressing is applied over the wound.

3. Tissue Mapping and Examination
The layer of tissue that was removed is then labeled, mapped, processed, and mounted on a slide. All of this is done at an on-site laboratory. Creating a finished slide with the tissue specimen is the most time consuming part of the Mohs surgery day, taking between 1-2 hours for each stage. The slides are then examined under the microscope by the Mohs surgeon at the on-site laboratory, and the results are interpreted. Areas where skin cancer still remains is mapped accordingly.

4. Additional Tissue Removal
If the first layer displays residual skin cancer, another small layer of skin is removed from the cancerous areas only. This sample is again labeled, mapped, processed, and mounted on a slide for examination under the microscope. This process is repeated until all tissue removed is found to be cancer-free, at which point the excisional wound is prepared for closure.

5. Reconstruction
With the all of the cancer removed, the wound is then closed. The science of wound closure is complex and involves a profound knowledge of tissue anatomy and movement, balanced by knowledge of aesthetic outcomes. Based on the size and location of the wound, closure may involve simple side-to-side closures, flaps, or grafts. Sometimes, the wound is left open to heal by itself.

Medications
Certain medications can increase the risk of excess bleeding during the surgery. To reduce this risk, avoid taking ibuprofen, vitamin E, ginkgo, ginseng, and fish oil during the two weeks prior to the procedure.

Blood thinners such as aspirin, Plavix and Coumadin can also increase bleeding during surgery, but should continue to be taken if prescribed due to a previous serious condition such as a stroke, heart attack or blood clot. Discuss this with your Mohs surgeon during your surgical consultation.

On the day of your consultation, be sure to bring a list of all current medications, including vitamins and herbal supplements. Because the surgery can last several hours, any medicine needed during the day should be brought along as well.

Smoking
Smoking can affect the healing process for wounds. Avoid smoking for two weeks before, and two weeks following Mohs surgery.

The Day of Surgery
On the day of surgery, eat normal meals such as breakfast before arriving. Because the procedure may take between half a day to the entire day, consider bringing your lunch. Many patients also bring books or other entertainment to help pass the time while their tissue is being processed.

Initial Recovery
Before leaving, the physician will schedule a follow-up visit in one to two weeks to remove any stitches and evaluate healing.

While most wounds from Mohs surgery aren’t particularly painful, bruising and swelling may appear following the procedure and can last for up to two weeks. If pain relief is needed, acetaminophen (Tylenol) is recommended over ibuprofen or aspirin.

Skin Checks
It is important to continue regular skin cancer screenings following any diagnosis/treatment of skin cancer. These should be conducted every three to six months.

Scarring
While Mohs surgery generally yields better cosmetic outcomes than its other surgical alternatives, scarring is an expected outcome of the procedure. Depending on the location and extent of the cancer, secondary cosmetic dermatology procedures such as laser or surgical scar revision may be recommended to help improve its cosmetic appearance. Note that the appearance of the scar will continue to spontaneously improve for up to a full year following the procedure.

In addition to being an ACMS fellowship-trained Mohs surgeon and Board Certified Dermatologist, Dr. Julia Tzu is also a Board Certified Dermatopathologist. This means that your skin cancer tissue will be interpreted with a degree of expertise beyond most Mohs surgeons. In addition, our facility houses a selection of lasers, including a scar revision laser.

As a premier provider of dermatological services in NYC, our practice is committed to providing patients with the highest level of care. Contact us today to learn more about Mohs surgery, as well as a wide range of other cosmetic dermatology procedures.

Call Wall Street Dermatology to schedule a consultation with us today.