Mohs Surgery
MOHS micrographic Surgery is an advanced treatment process for skin cancer that
offers the highest possible cure rate for many skin cancers and simultaneously
minimizes the sacrifice of normal tissue. The MOHS surgical technique was
developed by Dr. Frederic Mohs at the University of Wisconsin from the
1950’s-1970’s. His technique has been modified over the years to arrive at the
technique used today. This treatment requires a highly specialized physician
that serves as a pathologist, surgeon and reconstructive surgeon; as well as,
nursing specializing in MOHS and histotechnological staff.
Some skin cancers are deceptively large, and may be far more extensive under the
skin than they appear from the surface. These cancers may have “roots” in the
skin, along blood vessels, nerves, cartilage or along scars. MOHS surgery is
specifically designed to remove these cancers by tracking and removing these
cancerous “roots.” The cure rate for MOHS micrographic surgery approaches 99%
for primary (untreated) cancers and slightly lower cure rates for secondary or
recurrent (previously treated) skin cancers, while limiting sacrifice of
uninvolved tissue. This provides the foundation for the best reconstructions and
limits scaring and disfigurement. MOHS micrographic surgery remains the most
effective method for curing non-melanoma skin cancers such as Basal Cell
Carcinoma, Squamous Cell Carcinoma and others (Sebaceous Carcinoma,
Dermatofibrosarcoma protuberans, Bowens Carcinoma, etc.) available in the world
today.
Patients often want to know how a defect is going to be reconstructed, how long
the process will take or how large the cancer is at the beginning of the day.
Unfortunately, this information is not possible to give at this time. MOHS
micrographic surgeons are often able to provide closure of the wound, following
tumor removal, at the time of surgery. However, patients with larger defects or
those affecting specialized anatomic structures following tumor removal may be
referred to a plastic surgeon, otolaryngologist (ear, nose, and throat surgeon),
ophthalmologist ( oculoplastic surgeon) should the MOHS surgeon not be able to
do son on the day of surgery.
It is important to note that MOHS surgery is not an appropriate treatment for all
skin cancers. Cancers in areas such as the nose, ears, eyelids, lips, hairline,
hands, feet, and genitals as well as previously unsuccessfully treated are great
candidates. Most insurance policies cover the costs of MOHS surgery and the
reconstruction of the surgical area. Please contact your insurance carrier
directly for the most current payment information.
Dr. Colleen ManInnis, M.D.
MOHS Reconstruction
In the vast majority of cases, the wound can be dealt with on the same day as the
Mohs procedure. The anesthesia used will usually continue to be local anesthetic
sometimes supplemented with an oral sedative. In more difficult cases where it
is necessary for complicated reconstructive procedures to be performed it may be
necessary to send the patient through a hospital or surgery center where general
anesthetic or deep sedation is used.
There is a wide range of options in dealing with wounds created by Mohs surgery.
These include:
-
"Granulation" - This is allowing the wound to heal in on its own much as if a
person who falls and scrapes their knee or elbow and treats it with local wound
care of cleansing and applying topical ointment and bandages until it is allowed
to heal.
- Grafting - This may include harvesting of skin from another site on the body or
a xenograft which is processed porcine which serves as a biologic dressing
temporarily until the body can take over the healing much as in granulation.
- Flap closure - This can involve very small sites up to massive sites and may be
fairly simple and thin to multistaged procedures which may include skin and
muscle and cartilage as well.
- Tissue expansion - Tissue expansion is the last option, which is not used very
frequently, but involves inserting an inflatable reservoir or balloon under the
skin at the first procedure then inflating it until the body produces additional
skin, which can then be manipulated to close the wound.
Postoperative care is usually straight forward involving cleansing the wound
area and doing dressing changes. More complicated situations such as grafting
usually involve a dressing, which is allowed to stay on the wound for a few days
since it assists in immobilization of the graft so that the body can grow blood
vessels into it to nourish it and allow it to take. The number of postoperative
visits will depend on how complicated the wound is and how much oversight is
required. In some areas it may be possible to place dissolving stitches, which
require minimal if any care making the postoperative course less arduous for the
patient.
Complications of surgery are typically standard and include blood loss
especially if a patient is on blood thinners in which case a discussion should
be held with the surgeon as to the benefits or risks involved in stopping blood
thinners simply will increase blood loss. Infection is also a risk in
approximately 4% to 6% of the patients. The patients are not usually placed on
antibiotics routinely unless they are considered at greater risk for infection
usually due to the location of the wound being near an orifice such as the mouth
or ear canal, which has a higher number of bacteria. Scarring is a natural
process of the body healing the wound. This is a lengthy progression of healing
by the body, which incorporates multiple stages and types of collagen and
actually takes many months even though the wound is closed. Instructions
regarding optimal care of the wound postoperatively to minimize scarring are
given to the patient. There may be tissue loss or loss of part of a flap or skin
graft and these situations are handled on an individual basis. In most cases,
the body will slough off the necrotic or dead tissue and heal the area again.
Again, this will required additional care for the wound. Some patients have a
tumor, which invades the area of a nerve requiring interruption of the nerve
resulting in what is usually limited to loss of sensation in an area. There are,
however, a few superficial motor nerves that go to muscles, which can be injured
or removed in the course of surgery. Depending on the situation location, these
may or not be repaired at a later date. In some patients due to scar tissue and
damaged nerves, the patient can have chronic pain in the area. Fortunately, this
is a very rare complication of surgery that can occur.
Revisions of the surgical site are not often required. They are usually done in
6 to 12 months after the original surgery allowing the wound to mature and
soften as well as improve as time goes by. Initially any surgical site does not
appear pretty, but it usually improves significantly and satisfactorily as time
progresses.
KP/TC/2162741-000