Skin cancer is the uncontrolled growth of abnormal skin cells. It occurs when unrepaired DNA damage to skin cells triggers mutations, or genetic defects, that lead the skin cells to multiply in an uncontrolled manner. As cancer cells grow, they destroy surrounding normal tissue. The three main forms of skin cancer are:
- Basal Cell Carcinoma (BCC)
- Squamous Cell Carcinoma (SCC)
- Malignant Melanoma
All these cancers originate in the skin, but if untreated they can invade and destroy adjacent normal structures such as muscle and bone. Metastasis (spreading to other parts of the body) can occur if squamous cell carcinoma and melanoma are left untreated—this can be fatal. It is important to know that one type of skin cancer does not ‘turn into’ another type of skin cancer.
Any new growth on the skin or a sore that does not heal could be skin cancer. If a doctor thinks a skin growth may be cancer, a biopsy is often performed. The biopsy is used to confirm or rule out a diagnosis of cancer. The type and site of cancer determines what treatment to use.
There are several effective methods for treating skin cancer. Which method is chosen will depend on cancer type, size, location, and prior treatments:
- Electrodesiccation – involves scraping and burning with an electric needle
- Cryotherapy – liquid nitrogen is used to freeze cancerous tissue
- X-ray – a radiation oncology doctor uses radiation beams to kill the cancer cells
- Surgical Excision – scalpel removal with margins followed by stitching
- Mohs Micrographic Surgery
Mohs Micrographic Surgery is a highly specialized, highly effective technique for the removal of skin cancer. The physician serves as surgeon, pathologist, and reconstructive surgeon. This technique relies on the precision and accuracy of a microscope to trace and ensure complete removal of skin cancer. With specialized pathology training, a Mohs Micrographic surgeon can evaluate the complete margin (or edge) of tissue that is removed, and identify any microscopic cancer ‘roots’ that may be present but otherwise invisible to the naked eye. The procedure was developed in the 1940s by Dr. Frederic Mohs and has been refined and modified over the years.
Mohs Micrographic Surgery not only has the highest cure rate of all treatment methods, but it creates the smallest possible surgical defect, permitting the best cosmetic result. Unlike other methods of treatment, Mohs Micrographic Surgery does not rely on surface inspection to judge the extent of the skin cancer. What one sees on the surface may only be “the tip of the iceberg.” If the tumor is not well defined, if it blends into the normal skin, or if it is mixed with scar tissue from a previous operation, a surgeon might either remove too little and leave tumor behind or overcompensate and remove too much. Mohs Micrographic Surgery, using microscopic control, allows the surgeon to trace out the extent of the tumor and remove only diseased tissue.
‘Slow Mohs’ is a term occasionally used to describe a staged excision. A staged excision is sometimes used to remove skin cancer and involves the utilization of an outside pathologist to analyze removed tissue. With this technique, only a very small percentage of the surgical margin is actually analyzed. Only true Mohs Micrographic Surgery analyzes 100% of the surgical margin, which is critical in ensuring complete tumor removal. Mohs Surgery occurs over one day and is the most precise method of removing cancer. A staged excision occurs over multiple days and is less precise in removing cancer.
Most often, the wound can be stitched together. At times, the wound may need a skin graft or a skin flap (skin loosened and moved into the wound). Sometimes, the wound can be left to heal by itself. There are often multiple healing options. Your Mohs Micrographic Surgeon will discuss options with you to facilitate the best possible choice.
All surgical procedures have the potential for some degree of visible scarring. The appearance of post-Mohs surgical scarring depends on several factors, including size and location of the final defect, individual characteristics, and the reconstruction options available.
No. The surgery is performed with local anesthesia. This is generally safer than being put to sleep and is very well tolerated. An anti-anxiety medication may be prescribed if needed, although this is often not needed.
Plan to be at the office for the entire day. Sometimes skin cancers appear small on the surface yet have ‘roots’ that are identifiable under the microscope. The length of your day is completely unpredictable. Every time we remove tissue, the lab must then process it before it can be evaluated under the microscope. Therefore, you may have a significant amount of ‘down time’ during your visit. Please bring a book or electronic device to entertain yourself as you wait. Additionally, you should bring any medicines and prescriptions you may need throughout the day. You should also bring snacks and a lunch.
Discomfort, if it should occur with this procedure, is usually mild and can be managed with Tylenol and/or Ibuprofen. Do not take aspirin or aspirin-containing products (Excedrin, Anacin, etc.) unless prescribed by a physician. A pressure dressing will be applied to the wound and should be left in place for 1-3 days to minimize swelling and bleeding. Although some minimal bleeding is typical, brisk bleeding after surgery is infrequent. If brisk bleeding occurs, lie down, take some gauze or a dry washcloth and apply firm pressure for twenty minutes (by the clock) on the wound. Do not remove the pressure prior to this. If the bleeding persists, contact your surgeon.
Other problems that may occur include black and blue marks, swelling, and redness for approximately 2 months and a bumpy suture line for approximately 6 months. Rarely, if the skin cancer involves nerves of the skin, surgical removal can lead to numbness or muscle weakness in the area. Numbness usually resolves in 12-24 months, but may, occasionally, be permanent. On very rare occasions, a patient may experience sadness and emotional lability after the procedure. These symptoms generally resolve after 2 weeks. Please notify the office if you are experiencing these feelings so that we may refer you to a specialist.
The main goal of Mohs surgery is to remove skin cancer as completely as possible and prevent recurrence. Although the cure rate is not 100%, it offers the highest cure rate of any available procedure. Most patients never require further treatment.
Yes. We recommend that you have a driver for after surgery. If someone cannot stay with you during the day, you should at least coordinate a ride home and assume you will not be able to drive yourself. It is helpful to have someone with you to learn how to perform the required post-surgical wound care.
You should take all of your regularly prescribed medications as usual, unless directed otherwise. You should also bring any medication you may need throughout the day with you.
Occasionally, the physician will recommend that you take an antibiotic prior to your surgical procedure. In some instances, antibiotics will be prescribed at the conclusion of your surgical day.
Yes. We recommend significantly limiting your activity for the 24-72 hours following surgery. We recommend avoiding any strenuous activity, heavy lifting, or bending over for the first week after surgery. Please do not schedule surgery before any vacations, public outings, or family activities. Most patients must return for stitch removal 1-2 weeks after surgery.
At Deaconess, we would like for you to have the time off that you need for a full recovery from your surgery. One of our staff will be happy to fill out any forms that you may have for medical leave. Once the form is complete, your physician will sign the form. A work excuse will be given for the time period from the day of surgery until your pressure bandage or tie over dressing is removed. Your return to work date will be the day immediately following the pressure bandage or tie over dressing removal from a successful surgery. The form will indicate your return appointment (day and time) for suture removal. Any activity restrictions will also be noted.
- A local anesthetic will be injected into the area of surgery. This is the only part of surgery that will cause any discomfort – the sensation of stinging or burning.
- Once the area is numb, a small layer of tissue will be removed. Unless the cancer is quite small, more surgery is almost always required.
- The small amount of bleeding will be stopped with a machine that coagulates the blood vessels, a dressing will be applied, and you will wait in the operating room.
- This tissue will be brought back to the laboratory, where it will be examined for the presence of skin cancer. The tissue is processed, and microscope slides are prepared and examined. This process takes 90 to 120 minutes.
- If microscopic examination reveals remaining tumor, a map is drawn indicating the precise location.
- Additional anesthetic is injected to reinforce the first injection. In most cases, the initial anesthetic has not worn off and you feel little or no discomfort.
- The second stage now involves the removal of another layer of tissue – but only where the map indicates residual cancer. The healthy tissue is left alone; only the diseased tissue is excised.
- The tissue is brought back to the laboratory and the process is repeated until all evident cancer is removed.
- Once your skin cancer has been removed, Dr. Surprenant will discuss the best option to repair your wound. Unfortunately, we do not know the best option until the final size and depth of the wound is established and the cancer is completely removed.
- Occasionally it is necessary to delay a repair to optimize the wound bed for the best surgical outcome or to appropriate ample time to optimize the conditions for a complex reconstruction.