Mohs surgery

Mohs surgery is a specialized technique used to treat different types of skin cancer. It’s typically performed under local anesthesia, meaning only the area being treated is numbed. 

Mohs surgery is commonly used to treat basal cell carcinoma and squamous cell carcinoma. It can also be used for more unusual skin cancers. Mohs surgery is especially effective for skin cancers that:

• Are in areas where protecting appearance and function are important
• Reappear after treatment or are likely to come back
• Have edges or borders that are hard to define

If the doctor who referred you sends proper information, the Mohs surgeon won’t need to meet with you before the surgery. But sometimes a consultation is necessary to help determine the best treatment and follow-up care.  

Advantages of Mohs surgery include:

• Single-visit outpatient surgery
• Healthy tissue is kept
• Leaves the smallest possible scar
• Highest cure rate for skin cancer that hasn’t been treated before

During Mohs surgery, the surgeon removes a thin layer of cancerous tissue and marks the edges with colored dyes. Your wound will be bandaged and you will wait while the lab work is done. 

The tissue is examined under a microscope to see if any cancer cells remain at the edges. If cancer cells are found, another layer of skin will be removed and looked at under a microscope. This process is repeated until no more cancer cells are seen. 

If more than one or two rounds are needed, the process can take several hours or more. Once all of the cancer has been removed, the surgeon will decide how to treat your wound. Options include:

• Healing naturally without stitches
• Stitching the wound together 
• Using a skin flap or graft (a reconstruction)

In most cases, a reconstruction can be done the same day. If surgeons with special skills are needed, you may be asked to schedule another appointment.

Mohs surgery uses a local anesthesia, which numbs only the area being worked on. You may feel some discomfort when the anesthesia is injected, but this usually lasts only a few seconds. Once the area is numb, the surgery itself should not be painful.

After the surgery, the area of the surgery may feel sore. Taking Tylenol^® can help. In some cases, you may need to take prescription pain medication for one to two days after surgery.

Before surgery, do the following unless your doctor tells you otherwise:

• Get an INR blood test within 10 days of your surgery if you take blood thinners (warfarin/Coumadin®). If your levels are higher than 3.0, we will reschedule your surgery.
• Let your care team know if you have a pacemaker or defibrillator. List this on your medical history and remind the surgical nurse about this the day of your surgery.
• Wash the area to be treated and surrounding skin with an antibacterial cleanser (such as Lever 2000, Dial or Cetaphil). Do this twice a day for two days before the surgery.
• Arrange to have someone be with you the day of surgery or be available to drive you home. 
• Don’t plan to do anything else the day of the surgery. Mohs surgery usually takes much or all of the morning, and may take most of the day. Our office has Wi-Fi and magazines. Feel free to bring books or other items to help pass the time.

The day of surgery:

• Take your normal medications the morning of the surgery. This includes any blood thinners or aspirin that a doctor has prescribed.
• Eat a normal breakfast and bring snacks. If you have a procedure planned with another surgeon the same day, follow his or her directions for eating.
• Do not put makeup on the surgical site and surrounding area.
• Do not wear perfume or cologne.
• Wear loose, comfortable clothing that’s easy to remove without disrupting a bandage.
• Bring an up-to-date list of your medications and allergies.

After surgery:

• For a week or so, limit physical activity. This includes gardening, bending over and anything that raises your heart rate.
• You may have some bruising or swelling around the wound, especially if the surgery is close to the eye. Resting after the procedure will help limit the chances of this.
• If you live outside of the Seattle area, you may want to spend the night after the surgery in the city or nearby. Several hotels near our clinic offer good rates and shuttle service.
• If you have discomfort after surgery, medications like Tylenol can help. Your doctor may prescribe stronger pain medication if needed.

Caring for the wound after surgery depends on the size and depth of the wound. We consider desired outcomes, healing time and chances of bleeding or pain. We also assess how the wound might pull on other areas when healing — for example, an eyelid. 

Options can include:

• Allowing the wound to heal without stitches. In some cases, the results can be as good as or better than stitching. 
• Sewing the wound closed. 
• Making an incision near the wound edge to transfer surrounding skin into the wound. 
• Taking skin from another part of the body to replace skin that’s been removed (a skin graft). 

We usually do the repair the day of the surgery. But if a surgical specialist is needed, the repair may be delayed by a day or more. There is no harm in this delay.

Recovery and wound healing time depends on the type of reconstruction:

• Stitches are typically removed after one to two weeks depending on if they’re on the face or the body. Stitch lines may look pink and bumpy at first but will improve over time. Occasionally stitch lines may benefit from dermabrasion (skin resurfacing). 
• Stitched wounds will continue to improve (redness, bumpiness) up to a full year after surgery. Most patients are pleased with the final results after surgery.
• Makeup or camouflage products can be used once the wound is fully sealed (typically one to two weeks after surgery). This helps hide the stitch lines while they heal. 
• We encourage a follow-up visit within six to eight weeks after surgery.

If you have stitches, they’ll probably need to be removed at our office. Someone on the care team will tell you when to make an appointment for this. 

All surgery will leave a scar. However, because Mohs surgery removes as little normal skin as possible, scarring is minimized. Redness or bumpiness related to the stitch lines usually gets better with time.

You can return for a follow-up visit as needed so we can check on your healing. Sometimes we suggest a touch-up surgery or dermabrasion (skin resurfacing) to reduce the appearance of visible marks.

Be sure to schedule follow-up visits with a general dermatologist or your primary care provider. While Mohs surgery has a high cure rate for skin cancer, there is a small chance that the cancer might return or another skin cancer will develop.  

Once you’ve had skin cancer, you have an increased risk of recurrence compared to people who have never had skin cancer.

An actinic keratosis (AK) is a common precancer that can turn into SCC. It looks like a scaly spot on the skin and may have some redness. The spots do not feel deep and tend to grow slowly. AKs usually affect older adults.

Patients may have a few or many AKs on sun-exposed skin. Treatments include freezing the area with liquid nitrogen or applying creams to remove or reduce the AKs. Spots that grow quickly or return after treatment should be checked to make sure they’re not cancerous.

BCC is the most common skin cancer. It usually occurs in areas that get sun exposure. Growth is typically slow, from months to years. BCC can look like a sore that doesn’t heal, a pearly bump, a scaly patch or a whitish area that looks like a scar.

Fortunately, BCC has a very low risk of spreading to other areas. But over time, it can grow both outwardly (like an oil slick) and deeply (like the roots of a tree). This can impact other areas of the skin, especially areas on the face like the nose, eyelids or ears.

If not treated, BCC can invade the body deeply, making a cure increasingly difficult.

Treatment includes:

• Prescription creams 
• Surgery (including scraping or removing the area)
• Mohs surgery
• Radiation 
• Chemotherapy (a cancer treatment; used for difficult cases)

To determine the best treatment, we assess the expected cure and results. In many cases, surgery may produce the highest cure rate, especially for facial areas.

Mohs surgery is usually recommended. It offers the highest cure rate as well as precise removal of the affected skin. Healthy skin is not touched.

Melanoma is the third most common skin cancer. It usually looks like an irregular mole. But it can also look like a rapidly growing bump. One type of melanoma looks like a patchy discoloration on the face or scalp that gets bigger very slowly.

ABCDEs of melanoma

Any suspicious or changing mole should be examined by a doctor. Early detection leads to higher cure rates.

Warning signs include:

• Asymmetry: One half of the spot looks different in shape or color than the other.
• Border: The edges of the spot are irregular or jagged instead of smooth.
• Color: The spot has more than one color — brown, black, white, blue and red.
• Diameter: Most melanomas are larger than 6mm, the size of a pencil eraser.
• Evolving: A change in size, shape or color of a spot may be a warning sign of melanoma.

It’s important to find out how deep the melanoma is as early as possible. This can help keep it from spreading. If caught early, melanoma can be cured by surgically removing the affected area of skin. This procedure can often be done under local anesthetic.

If the melanoma is deep, more testing or treatment may be needed. This may include a biopsy of the lymph nodes and additional medical treatment.

SCC is the second most common skin cancer. It can look like a scaly patch or a sore on sun-exposed skin. SCC can be tender, painful or have no symptoms at all.

Unlike BCC, SCC can grow quickly and look like an enlarged pimple in just a few weeks. SCC can be cured by removing it completely. Sometimes it has a high risk of regrowth after being removed. It can also spread to other parts of the body.

Treatment can include:

• Surgically removing the affected area. Smaller areas may be treated with scraping procedures. Mohs surgery is usually recommended for SCC on the face, scalp, hands or shins. 
• Radiation instead of surgery. But usually radiation is used as a treatment for difficult cases after surgery.
• Chemotherapy, if the SCC is advanced.