Mohs Micrographic Surgery
The Mohs process begins with Dr. Rogers removing the visible skin cancer with a thin margin of normal appearing skin. This tissue is then processed in an on-site laboratory by a specially trained technician; she freezes, cuts, and stains the tissue to be examined under a microscope. Dr. Rogers then reads the slides, looking for any remaining skin cancer present at the margins. If skin cancer is found at the margins, another layer of tissue is removed in the identified area, and the process is repeated. Each layer approximately takes 1-2 hours to process. Once the margins are cancer-free, Dr. Rogers will decide how best to close the defect after removing the tumor, usually with the use of stitches.
With this technique, fellowship-trained Mohs surgeons are able to precisely identify and remove the entire skin cancer while leaving as much healthy tissue as possible. This minimizes the resulting scar and optimizes the cosmetic outcome. Mohs surgery is the treatment of choice for basal and squamous cell cancers of the head, neck, hands and other cosmetically sensitive areas. Mohs surgery is NOT used for melanoma skin cancers in our office.
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Medications
We suggest that you continue to take all of your prescribed medications up to, and including, the day of your surgery. This includes blood thinners such as Aspirin, Plavix, Coumadin, Eliquis and Xarelto. Although these medications may increase your risk of bleeding during and after your surgery, this is a minor concern when compared to the serious complications that could occur if these prescribed medications are stopped.
If you take ibuprofen (Motrin, Advil) or other anti-inflammatory medication (Aleve, Naproxen, etc) for pain, we do suggest you discontinue these medications at least 4 days prior to surgery. Tylenol (acetaminophen) may be taken as a substitute if needed and you have no liver issues.
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Day of surgery
Patients undergoing Mohs surgery at our office usually are scheduled in the morning because the procedure may last from a few hours to the entire day depending on the size and complexity of the skin cancer. Please plan accordingly with your schedule and bring something to do while you wait (such as a book, ipad, laptop, knitting, etc). Take a shower and eat a good meal before coming in.
After surgery, you will have a pressure bandage placed which must stay on and dry for the first 48 hours. Stitches typically stay in for 5 days to 3 weeks and you will need to return to the clinic to have the stitches removed. You will need to refrain from exercise, heavy lifting or other strenuous activity for the first week after surgery. Traveling after surgery is generally not advised. Further post-care instructions will be explained by our nursing staff during your appointment. The goal of Mohs surgery is to remove the skin cancer in its entirety while keeping the scar as small and hidden as possible. At times, complex repairs are required which may benefit from additional treatments. Starting as soon as one month after your surgery, Dr. Rogers provides a scar follow-up appointment to make sure you are healing well and optimum results are achieved. As with every procedure offered at our office, please call us with any questions you may have before and/or after your surgery.
*For more detailed information on preparation and day of the surgery, keep reading below after FAQ’s.
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What is the training of a Mohs surgeon
Mohs surgeons are dermatologists who specialize in skin cancer surgery and are members of either the American College of Mohs Surgery or the American Society of Mohs Surgery. The College requires its members to complete a one year fellowship in Mohs surgery, reconstruction and pathology. During this year, the surgeon must perform at least 500 cases of Mohs surgery under the supervision of a Mohs College trained fellowship director. In comparison, American Society of Mohs Surgery members perform Mohs surgery without completing the additional year of training in Mohs surgery, reconstruction and pathology.
Dr. Rogers is a board-certified dermatologist and fellowship trained Mohs surgeon who has performed more than 5,000 cases of Mohs surgery. She is clinical faculty at the University of Washington and an active member of the American College of Mohs Surgery.
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What are the advantages of a Mohs surgery
Mohs surgery offers the highest possible cure rate for the treatment of skin cancer. Mohs surgery also allows the physician to remove as little normal tissue as possible around the tumor, and thus, in many cases, provides a superior cosmetic result.
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How many stages of surgery will I undergo
The goal is to remove the entire tumor with the first stage. On average, only 50% of patients are cleared on the first layer because many skin cancers have microscopic components that cannot be seen with the naked eye. Additional layers are taken until the entire skin cancer is removed while removing as little as possible of the surrounding normal skin.
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How long should I plan on spending in the doctor’s office
The length of time depends on the size of your skin cancer and the number of stages that are required. You can expect to stay at least 4 hours, but some surgeries have required the full day. Unless specifically told by the nursing staff, you may drive yourself to and from our office. There is parking available in our parking garage where we validate for the first 4 hours. Please see the following link for more detailed instructions on how to access our garage: https://mdinseattle.com/contact-modern-dermatology/
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What happens after the surgery is completed
There will be a wound following the completion of the Mohs surgery. There are several options to allow for healing. These options include allowing the wound to heal by itself, suturing the wound closed or using a skin graft or flap to close the wound. In almost all cases we perform the repair of the wound on site, immediately following Mohs surgery. It is, however, always your option to select another surgeon for reconstruction of the wound.
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Will there be any office visits after the surgery
Yes. We will need to see you to remove the stitches and then at least once again in follow up. The frequency of these return visits will depend upon the size and location of your skin cancer. After the short-term follow-up visits are completed, long-term follow-up can be performed by your referring physician.
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What is a Basal Cell Carcinoma
A basal cell carcinoma is the most common type of skin cancer. It rarely, if ever, metastasizes (spreads to other parts of the body); however, if it is not removed, it will continue to grow and damage the surrounding structures. It is thought to be caused by sun and/or radiation exposure.
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What is a Squamous Cell Carcinoma
A squamous cell carcinoma is the second most common type of skin cancer. It has a greater chance of spreading to other parts of the body than a basal cell carcinoma, but this is still an uncommon phenomenon and is most frequently seen in long-neglected tumors. Like basal cell carcinomas, squamous cell carcinomas are thought to be caused by sun and/or radiation exposure. They can also be caused by the human papilloma virus (HPV).
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What are the chances that my skin cancer will return after the Mohs surgery
Mohs surgery offers the highest cure rate of any treatment method. If your skin cancer has never been treated before, then the chance of recurrence is less than 1%. If your lesion has been treated before, then there is a less than 5% chance of recurrence.
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What are the alternatives to Mohs surgery
Mohs surgery is the treatment of choice for complicated basal and squamous cell skin cancers, including skin cancers that were previously treated, skin cancers of the head, neck, hands or feet, in patients with a history of multiple skin cancers, and patients who are immunosuppressed or under the age of 40. For uncomplicated skin cancers, alternative treatments include routine surgical excisions, destruction of the tumor by scraping and burning (electrodessication and curettage), photodynamic therapy, or topical therapies. The cure rate of these treatments is lower than with Mohs surgery.
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Are there any pre-operative instructions that I should follow?
Yes, please see the information in the following section for more complete instructions. To summarize, eat breakfast and continue your medications as prescribed on the day of surgery. Non-prescribed aspirin and herbal supplements should be stopped at least one week prior to surgery. Anti-inflammatory medications taken for pain should be avoided for 4 days prior to surgery. Smoking should be decreased or stopped at least 1 week prior to surgery and alcohol avoided for two days prior to surgery.
Preparation for Mohs Surgery
We will review this information with you at the time of your Mohs surgery consultation. If you are traveling a long distance and do not want to have a consultation prior to your surgery appointment, please let us know and we will try to make other arrangements.
WORK, EXERCISE AND OTHER PLANS
Work
Take the day off from work and plan on spending the entire morning with us. There is swelling, redness and bruising after surgery. You will have a pressure bandage on for 48 hours and stitches for 5 days to 3 weeks. The pain after surgery is usually minimal and you should be able to return to work the next day IF you can tolerate having a bulky bandage on and you remain sedentary. If this is not the case, we are happy to provide a doctor’s note to ensure you are able to rest.
Exercise
Prior to surgery, please get caught up on household activities (for example: mow the lawn, clean the house, or go to the grocery store). After surgery, it is important to take it easy to decrease your risk of bleeding and infection and to minimize scar formation. Furthermore, for at least one week after surgery while your stitches are in, you will need to refrain from exercise, heavy lifting or other strenuous activity.
Plans
Let us know ahead of time if you have any events or travel plans scheduled in the month after your surgery. You may want to reschedule the surgery to a time you are less busy.
MEDICATIONS
Blood Thinners
We suggest that you continue to take all of your prescribed medications, up to and including the day of your surgery. This includes blood thinners such as aspirin, Plavix (clopidogrel), Coumadin (wafarin), Xarelto (rivaroxaban), Aggrenox (aspirin and dipyridamole), Ticlid (ticlopidine), and Eliquis (apixaban). Although these medications may increase your risk of bleeding during and after your surgery, this is a minor concern compared to the serious complications that could occur if these prescribed medications are stopped and you formed a blood clot. If you are concerned with these recommendations, please speak with your prescribing physician prior to your scheduled surgery. Do not stop these medications without clearance by a physician.
If you are taking two blood thinning medications, for example aspirin and Plavix, please speak with your prescribing physician prior to your scheduled surgery. If possible, we will want to stop the aspirin at least one week prior to surgery.
Stop aspirin or any other aspirin containing product, which is not prescribed by a physician, two weeks prior to surgery.
Pain Medications
If you take ibuprofen (Motrin, Advil) or other anti-inflammatory medication (Aleve, naproxen, others) for pain, we suggest you discontinue these medications four days prior to surgery. Tylenol (acetaminophen) may be an alternative if needed.
Herbal Supplements
If you take herbal supplements such as ginko, garlic pills, ginseng, vitamin E, we recommend that you discontinue these two weeks prior to surgery as they can thin your blood.
Alcohol
Drinking alcohol can increase your chance of bleeding during or following your surgery. Please refrain from drinking two days prior to your surgery.
Smoking
Tobacco interferes with wound healing. We realize it can be very difficult to stop smoking, but please try to limit your smoking starting one week prior to surgery and two weeks after surgery for better wound healing.
MEDICAL CONDITIONS
Drug Allergies
Let us know if you have a history of allergies to any medications and if you have experienced reactions to anesthesia or epinephrine in the past.
Pacemakers and Pacemakers with Defibrillators
Mohs surgery can safely be performed on patients with pacemakers, but special care must be taken when sealing off blood vessels during the surgery. Please notify the nurses and Mohs surgeon of your pacemaker prior to surgery.
Heart Valve Replacement
According to the recommendations of the American Academy of Dermatology and American Heart Association, antibiotics prior to Mohs surgery are only indicated for patients having surgery on the mucosa (lip, mouth, groin). If you have had valve replacement surgery, talk to your cardiologist about taking prophylactic antibiotics prior to surgery. If your doctor recommends it, these antibiotics can be obtained from your cardiologist or from us on the day of surgery.
Joint Replacement
According to the recommendations of the American Academy of Dermatology and American Association of Orthopaedic Surgeons, antibiotics prior to Mohs surgery are only indicated in patients having surgery on the mucosa (lip, mouth, groin). If you have undergone hip, knee, or other joint replacement in the past 2 years we recommend that you talk to your orthopedic doctor about taking prophylactic antibiotics prior to surgery. If your doctor recommends this, the antibiotics can be obtained from your orthopedist or from us on the day of surgery.
History of Bleeding Disorder
Let us know if you have any history of a bleeding disorder, or if you have experienced unusually heavy bleeding during past surgical or dental procedures.
Mohs: What to Expect the Day of Surgery
You will arrive at our office in the morning. The procedure may last from several hours to the entire day depending on the size and complexity of the skin cancer. Please clear your schedule for the day and arrive with something to do while you wait.
On your surgery day, please shower, have breakfast and take your usual medications. We will review the process of Mohs and answer any questions you may have. A local anesthetic will then be used to numb the surgical site. Once numb, you will be draped with surgical towels and Dr. Rogers will remove the entire visible tumor with a thin margin of normal-appearing tissue. A temporary bandage will be placed to cover the site. You will then be able to relax in our comfortable waiting area where there is an assortment of beverages, snacks, and reading material.
While you wait, the tissue will be processed in our on-site laboratory and made into microscope slides. This process takes approximately 1-2 hours. Once the slides have been read by Dr. Rogers, you will be brought back into the surgical room. If there is skin cancer present at the margins, Dr. Rogers will take another layer of skin and this cycle will be repeated until the entire cancer is removed. Once the margins are cancer-free, Dr. Rogers will plan how best to close the opening made by removing the tumor. The closing usually requires stitches and can take from 10 minutes to an hour depending on the size and location of the skin cancer. Once done, the nurse will apply a pressure bandage that stays in place for 48 hours and explain how to care for the site.
After Surgery
Discomfort after your surgery is usually minimal. There will be some discomfort for the first 24 to 48 hours after surgery. If needed, take up to two 500mg of extra strength Tylenol (acetaminophen) AND two 200mg of Advil (ibuprofen) every 4 to 6 hours after surgery for pain. Do NOT take more than eight Tylenol (acetaminophen) or six Advil (ibuprofen) during a 24 hour period. Do NOT take Tylenol if you have liver problems. Do NOT take Advil if you have kidney problems. To lessen the discomfort, relieve swelling, and minimize bruising, an ice pack may be applied over the dressing every 1-2 hours for twenty minutes. You may notice a small amount of blood under the dressing which is normal.
Although most Mohs surgeries are relatively small, it is important to take it very easy while your sutures are in place to decrease your risk of bleeding and infection. It is our recommendation for you to refrain from exercise, heavy lifting, strenuous activity as well as limit or stop smoking during this time to allow for proper healing and a better cosmetic outcome.
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Cancellation Policy
Modern Dermatology requires a 48-hour notice of any changes or cancellation of any medical appointments. If you reschedule, no show or cancel your appointment within 48 hours, you will be required to pay $50.00. If a third late cancellation, reschedule or no show should occur, within the same calendar year, you will either be discharged from the practice or the cancellation fee will increase to $150.00. This amount is due before scheduling any future appointments.
*This policy is subject to change without prior notice.
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New Patients
Modern Dermatology requires a 48-hour notice of any changes or cancellation of any medical appointments. If a new patient reschedules, no shows or cancels their appointment within 48 hours more than twice, no future appointments will be scheduled.