MOHS MICROGRAPHIC SURGERY

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1 MOHS MICROGRAPHIC SURGERY UMass Memorial Medical Center 55 Lake Avenue North Worcester, MA (508) Dr. Mary Maloney

2 This booklet is intended to explain Mohs surgery to you. It is not, however, intended to be a substitute for a consultation session with the dermatologic surgeon. Please feel free to schedule a consultation if you so desire. WHAT IS MOHS MICROGRAPHIC SURGERY? Mohs micrographic surgery was developed by Dr. Frederick Mohs in the 1940 s as a precise method of treating certain skin cancers. It combines surgical removal of the cancer with immediate microscopic examination of the removed tissue in a way to insure that the tumor has been completely removed. All margins are carefully examined. Unlike other methods of treatment, Mohs surgery does not rely solely on what the physician can see with his or her eyes. Mohs surgery, using the microscope to check the skin that has been removed, allows the surgeon to trace out all of the tumor and remove only the diseased tissue. It has the highest cure rate of all methods of treating skin cancer, and also allows us to save as much normal, healthy tissue as possible.

3 HOW EFFECTIVE IS MOHS SURGERY? Using the Mohs surgical technique, the percentage of success is very high, often 96% to 99%, even if other forms of treatment have failed. WHAT TO DO BEFORE SURGERY? Aspirin or aspirin containing products may increase the risk of bleeding during and after surgery. Two weeks prior to your surgery, we ask that you do not take these products (including Anacin, Bufferin, baby aspirin) UNLESS you are taking these medications under a doctor s advice. We realize that many patients take aspirin to purposely thin the blood to prevent heart attacks. If you have been instructed to take an aspirin daily by your doctor, we recommend contacting him or her to ask about temporarily stopping the aspirin. Please also let us know if you take blood thinning agents such as Coumadin or Heparin. DO NOT stop your coumadin without specific instructions from your primary care doctor or cardiologist. Three days prior to surgery, we ask that you avoid drinking alcohol as alcohol may also increase bleeding. On the morning of your surgery, you may eat a light breakfast unless instructed otherwise. Please take any medications you normally take. Also, on the morning of surgery, please avoid wearing any makeup or moisturizers.

4 Because the procedure can sometimes extend into early afternoon, you and your companion may want to bring along a light snack or lunch. You may also want to bring along reading material or another quiet activity as there is some waiting time between stages. WHAT DOES THE SURGERY INVOLVE? The Mohs team taking care of you will consist of the Mohs surgeon, a Mohs fellow ( a dermatologist who is doing a fellowship training in Mohs surgery), an assistant and a histotechnologist who will process the tissue. Mohs surgery is an outpatient surgical procedure performed under local anesthesia. The surgery is performed in steps or stages. The first part is the actual surgery and normally takes about minutes. The other part of each stage involves the preparation of the tissue specimens and the surgeon s examination of the tissue under the microscope. This normally takes about minutes. The number of stages is dependent on the size and depth of the tumor. The actual procedure is as follows: You will be brought into the surgery room where your blood pressure, pulse and history are checked and photographs taken. The area is cleaned with a disinfectant solution and a local anesthetic called Lidocaine is injected to numb the area. The local anesthetic is the only part of the surgery which should hurt. You will notice a stinging or burning sensation that will last only a matter of seconds. Once the area is numb, the obvious part of the tumor is removed. A thin layer of tissue is then excised. The small amount of bleeding is stopped with a

5 hyfrecator (a machine which seals off blood vessels), a dressing is applied and you are free to go to the waiting room. The removed skin is divided into pieces and marked carefully with colored inks to distinguish top from bottom and left from right. By doing this, we are able to pinpoint the exact location of any remaining tumor detected during microscopic examination. If more cancer is found, you are returned to the surgical area, additional anesthetic is injected and a second stage of Mohs surgery is performed. Tissue is removed only where tumor remains and healthy tissue is left alone. The average tumor requires two to four stages for removal. Do not be discouraged if your cancer is not removed in one stage. We are tracing the extent of the tumor very carefully, thereby removing as little normal tissue as possible. Only by removing small layers carefully can this be accomplished. WHAT HAPPENS AFTER THE CANCER IS REMOVED? After the cancer is removed, there will be an open wound remaining. At this point, there are several alternatives which depend on the size and location of the wound. Most often, the wound will be repaired by Dr. Mary Maloney on the day of surgery. Sometimes, only a small number of stitches are required to repair the wound. Occasionally, a small graft or skin flap is required for repair. Additionally, allowing the wound to heal in on its own is the treatment of choice and may produce a result equal to or better than suturing. If the defect is very extensive, another specialist may be consulted for

6 the needed reconstruction. All of these alternatives will be discussed with you after the cancer is removed. WHAT CAN I EXPECT AFTER SURGERY? After the anesthetic wears off, there is surprisingly little pain. Tylenol is frequently sufficient to relieve any discomfort. As aspirin and aspirin products (such as Excedrin and Anacin) may increase the possibility of bleeding, these products should be avoided. Occasionally, a stronger pain medication will need to be prescribed. Alcohol should be avoided following surgery as it dilates the blood vessels and could lead to bleeding problems in the wound. We also recommend that heavy lifting and strenuous activity be avoided. After surgery, go home, relax and take it easy. A certain amount of redness and swelling is completely normal in the area of the surgical wound. This gradually resolves over several days to a week. Along with this, there may be some bruising. This is usually a little more long lasting but should resolve in one to two weeks. If the redness, swelling or bruising increases or does not improve, you should contact the office. Infection is always a risk of surgery, but fortunately, it is an infrequent problem after skin surgery. Infection usually does not show up right after surgery but rather several days later. As was mentioned before, redness and swelling occur normally after surgery and becomes less and less apparent with each day. If, after several days, redness, swelling and discomfort begin to increase in severity and/or if pus begins to come from the wound, then this may represent

7 an infection and you should call the office. An antibiotic will be prescribed if necessary. Bleeding is also only rarely a problem after skin surgery. But, since some patients come from far away, it is important to be prepared in the unlikely event that bleeding should occur. If bleeding is going to occur, it does so almost always in the first 24 hours after surgery. Apply moderate pressure continuously to the dressing or directly to the wound with a clean gauze or washcloth for 15 minutes. If there is still active bleeding, remove the bandage and apply pressure directly to the site for another 15 minutes. If the bleeding still has not stopped, either call the clinic or page the dermatologist on call. If you are far away, we may recommend seeing a dermatologist near you or even going to the emergency room. After any form of surgery, there will be a scar. This is of particular concern, of course, when the surgery involves your face where most skin cancers occur. We make every attempt to give you the nicest scar possible and hide it within natural lines everyone has on their face. Most people are satisfied with the ultimate cosmetic result after skin cancer surgery, but it is important to be patient, allowing the scar tissue to naturally remodel. With some exceptions, we suggest that someone accompany you on the day of surgery. Because much of the time is spent waiting, try to bring a good book or at least a good conversationalist. We look forward to working with you. You should feel free to call us with any questions or problems.

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