Preparing for Mohs Surgery

Commonly Asked Questions:

1. What are the risks of Mohs surgery?

This lists the most common risks of Mohs surgery. It is not intended to be a complete list of all the potential complications that may occur with surgery.

• Scarring – it is impossible to cut the skin without leaving a scar. The aim of any surgery is to leave the least noticeable scar as possible and to hide it within the normal lines of the skin to make it less visible.

• Infection – the rate of wound infection is very low with this kind of surgery, generally less than 1 person out of 100. We aim to keep it this low by cleaning the skin and occasionally using antibiotics after surgery. If you do develop a wound infection, we treat it with antibiotics.

• Bleeding – there is a risk of bleeding whenever we cut the skin. We reduce this risk by cauterizing any blood vessels during the surgery. Rarely bleeding may occur after the surgery. We will let you know what to do if this occurs.

• Bruising and Swelling – are common after surgery. They usually begin the day after surgery. This may persist for up to 2 weeks while the skin is healing.

• Pain – some discomfort is expected after surgery; usually it is minor and controlled with Tylenol and ibuprofen. If pain is more severe, we will give you prescription strength pain medicines. Occasional discomfort may be felt during the healing phase of any wound (up to 6 months).

• Numbness – sometimes nerves can be damaged during the surgery. This may lead to areas of numbness (loss of feeling) in the surrounding skin. Usually this is temporary; sometimes it is permanent.

• Opening of the Wound – stitches stay in for 1-2 weeks. Rarely the stitches may not hold and come out before you are due back. This can happen for a number of reasons. You will need to contact us if this happens.

• Abnormal Scarring – scars keep on healing and maturing for up to 1-2 years. Sometime several months after the surgery the scar may begin to thicken. This is called a keloid scar. There are many ways of treating this.

• Recurrence of the tumor – Mohs surgery provides the highest cure rate of any form of skin cancer treatment. Nevertheless it is not a 100% cure rate and recurrences in rare cases can occur. Again this is very uncommon. If you do get a recurrence then Mohs surgery would be performed again.

• Additional Procedures at a later date may be required to reduce scar swelling, redness or thickening. Your Doctor will let you know if this is necessary.

2. Since the biopsy, the area appears to have healed. Do I still need surgery?

Most of the skin cancers have roots under the skin that are not visible with the naked eye. The biopsy is performed to sample the tumor, not to remove the entire tumor. Even though the surface of the skin has healed there is still tumor underneath the skin, which is why your doctor has referred you for Mohs surgery.

3. I have a special social event within 2 weeks of the surgery; should I still have the surgery?

Depending on how dangerous the tumor is, many cases can be delayed by 2-3 weeks without problems. It is not advisable to have surgery around the time of major events, as bandages and bruising can ruin a photograph.

4. Will I have pain afterwards?

Most wounds are typically minimally to moderately painful after surgery. Pain after surgery is typically worst the first two days after surgery, then gradually becomes minimal. If there is discomfort then take an over the counter acetaminophen (Tylenol) based pain killer. If you are still experiencing discomfort 1-2 hours after this, then take ibuprofen 400 mg. This combination of ibuprofen and Tylenol work particularly well for post- operative pain after Mohs surgery. If we suspect a wound will be more painful we shall give you a prescription for a stronger painkiller.

5. Will my cancer become a melanoma?

Basal cell carcinoma, Squamous cell carcinoma and Melanoma are all completely different types of cancer. One does not become the other. Each of them has early stages and more advanced stages of the disease, but they are still their own cancers.

6. Why did it take so long for this cancer to be diagnosed?

Your cancer may have been looked at by a doctor in the past that reassured you that it was nothing to worry about or that it was a pre- cancer and only needed a freezing treatment. It was not until the area began to change that the diagnosis was made. Some skin cancers are easy to spot; they look just like the pictures in the brochures and textbooks! But many are very difficult to detect; they can look just like non-cancerous skin growths or like areas of irritated skin, until they change significantly, enough for your doctor to suspect a skin cancer. This inevitably leads to a delay in diagnosis. The good news is that Mohs surgery has a very high rate of cure (up to 99%) for most skin cancers.

7. What would happen if I leave this area untreated and do nothing?

There are rare instances where a biopsy may cure a cancer but by far the majority of skin cancers are not removed by the biopsy. If left alone the cancer continues to grow wider and deeper under the skin. Basal cell carcinoma rarely spreads to other parts of the body, it keeps growing locally and eats away at skin and surrounding tissues. Squamous cell carcinoma does have a risk of spreading to other body parts. The longer the tumor is left the more this risk increases.

8. What are the chances of me getting another cancer?

Several studies have looked at this and suggest that about 4 out of 10 people (40%) will get another cancer in the next few (2-4) years. The cancer may not necessarily be on the face. Once you have had your surgery we do recommend that you have your skin regular checked by the dermatologist who referred you to our clinic every 6 months to a year. Some people with multiple skin cancers may have to be seen more often. The goal of doing frequent skin checks is to catch skin cancer at an early stage so they are smaller and easier to treat.

9. How should I select a Mohs surgeon to perform my surgery?

To get the best outcomes after Mohs Surgery, it is important to select a highly qualified surgeon who i) has had fellowship training in Mohs micrographic and reconstructive dermatologic surgery ii) has attained board certification in Mohs Micrographic Dermatologic Surgery by the American Board of Dermatology iii) is a fellow of the American College of Mohs Surgeons. This combination of advanced training and board certification ensures that your surgeon has the necessary experience and expertise in Mohs micrographic and facial reconstructive surgery for treatment of your specific type of skin cancer. Beyond that, select a surgeon that makes you feel well cared for, and well-informed of your diagnosis and treatment plan.

10. What training has a Mohs Surgeon had?

A Mohs surgeon is a board-certified dermatologist who has undergone additional training in skin cancer surgery. A fellowship-trained Mohs surgeon is a physician who has received a medical education, completed residency training in dermatology (study of the skin) with emphasis in dermatologic oncology (the study of skin cancer), dermatopathology (the study of skin and associated diseases under a microscope), and completed additional 1-2 years of fellowship training in Mohs micrographic surgery technique and advanced reconstructive surgery (surgical repair of the wound left behind after cancer removal using a wide array of plastic and reconstruction surgery techniques). Modern day fellowship training programs last 1-2 years during which time the surgeon is closely supervised while learning the removal of skin cancers, interpreting the findings under the microscope then repairing the defect left by tumor removal. Mohs surgeons who train via this route are inducted as fellows of the American College of Mohs Surgery (ACMS) (http://www.mohscollege.org). Only ACMS fellows have received rigorous, hands-on direction, education and review from experienced practitioners of Mohs surgery, completed a minimum of 500 Mohs surgery cases during training, and have the expertise of treating rare or unusual tumors, difficult tumor locations, and complex wound reconstruction requiring plastic surgery techniques. This combination of board certification and fellowship-training make ACMS members prime and trusted leaders in the field of Mohs surgery and skin cancer.

11. Do I need to bring someone with me?

Not necessarily, however, it is preferable for you not to drive on the day of surgery if you can help it. Some cancers on the face can require larger bandages on the first day that may interfere with vision or wearing glasses. Usually it is fine to drive the next day or two, as you will change to a smaller bandage. If you are given a medication to help with anxiety during the surgery, you will not be able to drive home legally, and will require a driver. Sometimes, people feel quite tired after having surgery and would rather have someone else drive. As long as there is not a dressing covering your eye, and you have not had any sedating medications, it would be okay to drive home yourself after the Mohs procedure.

11.What are the alternatives to Mohs Surgery?

Mohs surgery is not appropriate for all types of skin cancer. There are many different ways of treating skin cancers. The decision to use Mohs surgery depends on a number of factors relating to the cancer, its location, patient factors and prior treatments used.

Other methods that we use for treating skin cancer include the following;

Freezing it with liquid nitrogen: this is painful, can leave large scars and there is no microscope proof that the tumor has been removed. The degree of freezing needed is much greater than when we treat pre-cancerous lesions.

Scraping and burning (electrodessication and curettage): this is often used on the trunk, arms or legs where we have skin to spare, but the recurrence rate on other areas can be quite high, and the scars are often quite wide. Again, there is no microscope confirmation that the tumor is gone; any recurrent tumor will be mixed in with scar tissue, making it more difficult to remove using this method a second time.

Simple Excision: When a lesion is excised, we use a fixed margin, usually 4 mm around the tumor. Sometimes this is fine, again where we have skin to spare, but on the face and areas where the skin is very tight we prefer to take narrow margins. When the specimen is sent to the pathologists they only examine a few sections through it, so the recurrence rates are higher.

Anti-Cancer Creams: There are creams that have been around for many years, and new creams coming on the market that are being used to treat skin cancers. Obviously the idea of using a cream instead of surgery is very appealing. These creams have to be used for several months to work; they cause a lot of irritation on the skin and recent studies have shown that 1/3 of the tumors will come back. The creams do not get very far into the skin, so deeper tumors will not be affected; in addition, some tumors wrap scar tissue around themselves which acts as a barrier to the cream. For the reasons above, these creams have shown better results for thin tumors.

Your doctor has referred you for Mohs as they feel that this is the most appropriate method of treatment for the type of tumor you have. If there is an alternative treatment that may be more appropriate your Mohs surgeon will let you know.