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Mohs Micrographic Surgery

Mohs Micrographic Surgery is a specialized procedure used to treat certain skin cancers. With the highest cure rate, Mohs Surgery achieves superior cosmetic results. Watch this informative video:

What is Mohs Surgery?

Mohs surgery is a unique form of surgery developed by Dr. Frederick Mohs, a professor of surgery at the University of Wisconsin, over 50 years ago. Since that time, the technique has been refined, and it is now available in many major medical centers throughout the country. It is performed by a specially trained team, including a physician, assistant and technician. At the present time, it is the most effective treatment for several types of skin cancer. It allows for the complete removal of the cancerous tissue and preservation of healthy, cancer-free tissue. In this manner, the skin cancer is removed, but an excess of healthy skin does not have to be excised.

What is Skin Cancer?

Skin cancer is the most common form of malignant tumor that occurs in humans. It is characterized by the abnormal growth of skin cells that expand to form tumors in the skin.

  • Accounting for nearly half of all cancers, skin cancer is the most common of all.
  • The rate of new skin cancers diagnosed in the U.S. each year has doubled since 1973.
  • It’s important to detect skin cancer early when it is most likely to be completely cured.

Skin Cancer Types

Cancer is tissue which grows at an uncontrollable and unpredictable rate. In the skin, there are three main forms:

  1. basal cell carcinoma;
  2. squamous cell carcinoma, and
  3. malignant melanoma.

The names refer to the cell types in the top skin layer (the epidermis) from which these cancers are derived.

The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. If not completely removed, both frequently will invade and destroy structures in their paths. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are therefore easily cured.

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.

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 skin cancers. Skin cancer most commonly develops on the face and most sun-exposed parts of the body. Both, frequent childhood sunburn and cumulative sun exposure are important factors. Fair-skinned individuals develop skin cancer more frequently than dark-skinned individuals. Cancers of the skin are more common in the Southern United States.

Skin cancer also tends to be hereditary and occurs very frequently in certain ethnic groups, especially those with fair complexions such as Northern Italians and Celtics. Lightly pigmented skin in combination wih lifelong sun exposure confers substantial risk for developing skin cancer.

Other possible causes of skin cancer include X-rays, trauma, certain chemicals and rare genetic syndromes.

Skin Cancer Growth

Skin cancer begins in the uppermost layer of the skin, the epidermis. The cancer grows sideways on the surface of the skin and downward with roots; these can be compared to the roots of a tree. The persistence of certain skin cancers is similar to the persistence of weeds. They will continue to grow until all roots are completely eliminated.

Unfortunately, these root-like extensions cannot be directly visualized. Therefore, what is apparent to the naked eye on the surface of the skin may actually be only the visible “tip of the iceberg.”

How is Mohs surgery performed?

The skin cancer is removed in a series of steps. Initially, the cancerous tissue is removed as a thin layer of tissue. The tissue is then taken to our laboratory where it is processed and examined under the microscope. The tissue processing takes about an hour. By looking at the tissue under the microscope, we are able to precisely determine if any cancerous tissue remains. If cancer remains, another “layer” of tissue is removed, and the process is repeated. Usually, this process needs to be done two to three times to completely remove the tumor. You are awake during the entire procedure. Mohs surgery is the most accurate and precise method for skin cancer removal. However, it is a time consuming procedure. We will begin in the morning, and the procedure usually lasts into the afternoon. When the entire procedure is finished, you may return home. (Here is a diagram that shows the steps in the Mohs surgical procedure.)

Skin cancers may be treated by several methods, including surgical removal by excision (cutting away) with or without Mohs technique, and by curettage and electrodesiccation (scraping and burning), X-ray therapy, cryosurgery (freezing), and topical chemotherapy. Your physician’s recommendation for the best approach to treatment is based on the type, size, and location of the tumor, and history of any prior treatment.

Is there discomfort?

Because anesthetic is used to numb the area, there is no pain during the procedure. Injection of the local anesthetic stings briefly, but this quickly subsides. The surgical area will be re-anesthetized throughout the day as needed. Several hours after the procedure, some discomfort should be expected, although many patients have no discomfort. Tylenol taken every four hours usually relieves discomfort.

Is there any special preparation before surgery?

The following medications should be discontinued 10 days prior to surgery:

  • Ibuprofen (Motrin)
  • Vitamin E
  • Herbal medications
  • Persantine

Also, do not drink any beer, wine or other liquor for two days prior to surgery. Please note:

You must contact your primary care physician before discontinuing Coumadin.

Please continue taking blood thinners such as Coumadin or Plavix UNLESS otherwise advised by our office or your primary care physician. Please let our office know if you take antibiotics prior to dental precedures. We will determine if this necessary prior to Mohs Surgery. Please eat a light breakfast the morning of surgery. You should not wear a shirt that needs to be pulled over the head – a button down shirt is preferable. It is important to arrive on time for your appointment – a late arrival could result in cancellation of your procedure. As there will be time spent in the waiting room while we are processing the tissue, you may want to bring a book, magazine and/or companion. There is a television in the waiting room. Please arrange to have someone give you a ride home, as you will not be allowed to drive yourself after surgery.

What can I expect on the day of surgery?

Shortly after your arrival, you will be escorted to the procedure room. You will be asked to sign a consent form, which allows us to perform the procedure. You will then be assisted onto the operating table by one of our nurses. Next, the local anesthetic solution will be injected to numb the area.

Your physician will then remove a thin layer of tissue, which will be taken to our office laboratory for processing and examination. A device, called electrocautery, will then be used to stop any bleeding. This device makes a buzzing sound. The wound will then be bandaged and taped. You may then return to the waiting room while the tissue is being examined, which can take up to one hour. If examination of the tissue shows that cancer remains, this process will be repeated. As previously mentioned, multiple stages are usually necessary in order to eradicate the cancer.

What happens after the skin cancer is removed?

Once the cancer has been completely removed, we will decide how best to manage the wound that has been created by surgery. This depends on the size and location of the wound.

In many cases, the wound can be simply closed by suturing the edges together, resulting in a linear scar. If the wound is too large to do this, tissue from the surrounding area can be rearranged in order to close the wound. This is called a skin flap, and results in a non-linear scar. Skin grafts, or tissue “borrowed” from other areas, are also used to close wounds that cannot be managed in a simpler fashion. Occasionally, the site will be left to heal by itself, a process known as “healing by granulation”. If the wound is left to heal in this manner, daily bandage changes will be needed for approximately three to four weeks. We also work closely with reconstructive surgeons, and if necessary, they will be called upon to repair the wound. After the procedure, you will be given detailed written wound care instructions. The sutures will need to be removed in about one week.

What can I expect after surgery?

You will leave our office with a bulky bandage on the surgical site. The rest of the day should be spent quietly at home. It is normal to feel some discomfort after surgery, although some patients have none. Tylenol, two tablets taken every four hours should be taken for pain. Swelling will occur around the surgical site, and this will begin to subside in several days. If the surgery is around the eyes, a “black eye” may occur. You will need to keep the surgical site dry for at least 48 hours. The sutures will usually be removed in one week, so you should plan to be in town for the entire week following surgery. Here is a video on post-operative care:

Are there any risks?

All surgical procedures have risks. Mohs surgery is no different. Infection is very uncommon, but should it occur, you should inform us immediately. Minor bleeding or oozing may occur after surgery, and your written instructions will discuss the treatment. Whenever surgery is performed, a scar results. The size and appearance of the scar depends on the size, location and depth of the particular skin cancer. However, the scars resulting from Mohs Surgery are often hardly noticeable. The area immediately surrounding the surgical site is usually numb for several months following surgery. This usually returns to normal, however it may last for longer periods of time. Most skin cancers are superficial and do not invade deeply. Rarely, the tumor will extend deeply and invade a nerve that controls movement. If this occurs, removal of the tumor may injure the nerve resulting in loss of movement in an area of the face.

How can I improve my scar?

The single most important factor in optimizing the cosmetic appearance is complete cancer removal. If a skin cancer recurs after treatment, a larger scar results. Mohs surgery affords the highest possible cure rate, while removing the least amount of healthy tissue.

Once the cancer has been removed, the reconstruction of the wound is important in determining the final cosmetic appearance. Dr. Frank has extensive experience in reconstructing surgical wounds. He has performed thousands of these procedures.

Contrary to popular opinion, we do not feel that oral Vitamin C, topical aloe or topical Vitamin E significantly helps wound healing or scars.

Can touch-up procedures be done to improve my scar?

In the vast majority of cases, the resulting scar is cosmetically pleasing. Any scar may be further touched up and improved with a variety of techniques, such as injections, sanding (dermabrasion), laser, or further surgery. If some of the techniques mentioned would be useful in your case, we will be happy to discuss these with you. Remember, all scars improve with time.


My skin cancer has been treated several times. Will I ever be cured?

A frequent reason why you have been sent to us for Mohs micrographic surgery is that other forms of treatment have failed. This does not mean that you are cancer prone or have a hopeless case. It merely means that the methods used to treat you in the past were not effective enough to destroy all of your skin cancer cells. Because Mohs micrographic surgery uses a complete, systematic microscopic examination to search out the roots of the cancer, it cures almost all patients – even those in whom skin cancer has persisted in spite of several other treatment modalities.

What happens If I do not have my skin cancer treated?

All types of skin cancer will grow and invade nearby tissue. How fast a skin cancer will grow is unpredictable and varies from person to person. Sometimes skin cancer will destroy important structures such as the nose, lip or eye. Occasionally, skin cancers can cause death.


If you have a basal cell carcinoma, there is approximately a 99% chance that you will be cured with Mohs Micrographic Surgery. If you have a squamous cell carcinoma, your chance of cure is 95%. Followup visits to detect the rare recurrence are very important. After the initial postoperative period, you will return to your referring physician for routine skin care and tumor surveillance.


Later on, must I avoid the sun?

No, not entirely. We do not think that sunshine will be harmful to you as long as you provide yourself with adequate protection, avoid burning and use discretion.

As mentioned earlier, sunlight probably is the main cause of skin cancer and patients who have developed one skin cancer often will develop more at a later time. Protective clothing is the most effective method of sun protection. Wearing long sleeved shirt, hats and specially designed sun protective clothing is very important. For those areas that can’t be covered, we recommend that you liberally apply a sunscreen (with an “SPF” of 30 or greater) to all exposed areas, including the tops of the ears in men.

It is best to apply the sunscreen about 15 minutes before going outdoors. Be sure to reapply it liberally after swimming or exercising since most sunscreens wash off with water or perspiration.

Remember, it may not be necessary for you to restrict your outdoor activities or to change your lifestyle if you follow this advice.

Beth Israel Deaconess Medical Center Dermatology Department

How Can I Get More Information?

Call us: 603.889.4149