Mohs surgery is a safe and effective treatment for skin cancer, designed to remove thin layers of cancerous tissue until all of a malignant lesion is eradicated. What differentiates Mohs surgery from other dermatological cancer surgeries is that the microscopic examination on each layer of tissue is performed while the patient remains in the doctor’s office, so that more cancerous tissue can be removed if necessary. The procedure not only ensures that you leave the doctor’s office cancer-free, but that as much of your healthy tissue is preserved as possible. Mohs surgery has a 99 percent success rate in eliminating malignant tissue.
Reasons for Mohs Surgery
Mohs surgery is primarily performed to treat basal and squamous cell carcinomas, the two most common varieties of skin cancer, though at times, it is also used for melanoma.
Mohs surgery is useful in areas where preservation of healthy tissue is especially important.
Advantages of Mohs Surgery
- Exceptionally high rate of cure for primary (almost 100%) and recurrent (more than 95%) cancer lesions compared to other methods such as surgical excision, radiation, curettage and desiccation, and topical medications
- Immediate assurance that the cancer has been completely removed
- Convenience and safety of being performed under local anesthesia
- Only mild discomfort
- Maximum amount of healthy tissue left intact
- Less scarring than most skin surgeries
After a Mohs procedure, most patients can quickly resume normal activities, though they will have to protect the affected area. Any residual discomfort is easily treated with over-the-counter analgesics.
Preparing For Surgery
Patients, like their doctors, must prepare for Mohs surgery. We instruct our patients to prepare for Mohs surgery as follows:
- Don’t take any aspirin, ibuprofen, or vitamins for 1 week prior to surgery
- Continue taking prescribed anticoagulants, such as Coumadin or Warfarin
- Don’t drink alcohol for 24 hours prior to surgery
- Eat breakfast and take all prescribed medications on the day of surgery
- Bring a book to occupy yourself during downtime
- Bring someone for companionship and to drive you home
If you’re unable to keep your appointment for any reason, please remember to cancel at least 2 days in advance.
The Mohs Surgery Procedure
Mohs surgery is performed outpatient in Dr. Ragi’s office. It may be performed by a team of highly trained Mohs Surgeons (Dr. Ragi, and Dr. Lombardi). First, the treatment site is numbed with a local anesthetic. Then, thin layers of skin are removed, and each layer is examined microscopically to see if it contains malignant cells. Excision continues episodically until the cancer is completely removed, at which point the site is stitched closed.
Most Mohs procedures can be performed in three or fewer stages, and usually take between 3 and 4 hours. The length of the procedure depends on the size of the cancer. Most of your time will be spent waiting, while tissue is microscopically examined.
It is advisable for you to bring a book or a companion to help you pass the time during the intervals between excisions. If your surgery keeps you in our offices during the lunch hour, we’re happy to provide you with pizza and beverages.
How is Recovery from Mohs Surgery?
After surgery, you may experience mild discomfort, bleeding, bruising, swelling, or itching. Pain medication is prescribed if needed, although most patients require only over-the-counter analgesics. Your surgical stitches will remain in place for 1 to 3 weeks, at which point you’ll return to our offices to have them removed.
We’re committed to giving you results that will please you, both aesthetically and medically. Every effort will be made to eliminate as much scarring as possible, even when reconstructive procedures, such as skin flaps or grafts, are necessary. Our surgeons typically hide stitches in the skin’s natural creases, or in out-of-sight areas, to camouflage any unavoidable scars.
What are the Risks of Mohs Surgery?
While Mohs surgery is considered to be extremely safe, there are risks involved in any surgical procedure. These risks, may include:
- Bleeding from the wound
- Infection at the site
- Hematoma (bleeding into the wound)
- Development of a keloid (enlarged scar)
Complications are quite rare. Our concerned involvement helps to ensure that your experience with will be a positive one.
Mohs Surgery FAQs
What is Mohs micrographic surgery?
Mohs micrographic surgery is the most effective treatment for skin cancer, with a 99.9% cure rate. Unlike other methods, Mohs surgery allows a fellowship-trained dermatologist to microscopically examine 100% of the skin removed. This allows patients to leave the office reassured that they are free of any skin cancer.
In addition to the highest cure rate for skin cancer, patients benefit from this tissue sparing technique, assuring the least amount of tissue is removed.
Dr. Ragi, who was trained by Dr. Fredrick Mohs, has performed over 20,000 surgery cases. All of our surgeons have completed an American College of Mohs Surgery approved fellowship, the highest level of qualification.
How long will I be at the office?
Please allow at least 3 hours. Skin cancer is similar to a tree, although it may appear small above the skin, we cannot predict how deep it has spread within the skin. Because of Dr. Ragi’s dedication to removing the cancer and delicacy of the technique, the exact duration cannot be predicted. We will provide snacks while you wait in our spacious and comfortable waiting room.
Should I stop my blood thinners?
Please stop aspirin 1 week prior to the surgery. Please continue all other medications, including Plavix, Warfarin (also known as Coumadin) or other blood thinners. If you have any further questions, please discuss them with your prescribing physician.
Can I drive myself home?
Most patients are able to drive themselves home. Patients may not be able to drive home if the cancer removal is performed near the eye.
Will I have general anesthesia?
No. The procedure is performed with only local anesthesia, similar to what your dentist uses.
Will I have stitches?
Generally, patients leave the day of their procedure with stitches, which are removed 1-3 weeks later in our office. Unfortunately, all surgical procedures carry the risk of scarring, and Mohs surgery is no different. Rarely, a specialized plastic/reconstructive surgeon performs the closure, normally at the behest of the patient. It is important to note that the size and location of the tumor heavily influence scarring potential.
Will I need Mohs surgery again in the future?
The answer is “It depends.” There is little chance the lesion operated upon will return, as the success rates of Mohs surgery on sites not previously treated is over 99 percent. Does that mean you won’t, however, develop a new skin cancer? There is no way to tell that. If you have had a previous skin cancer, the odds of developing a new skin cancer are much higher. In fact, research shows that from 35 percent to 50 percent of people diagnosed with one basal cell carcinoma will develop a new skin cancer within five years.
Skin cancer is a simple matter of accumulating sun exposure, most of it when you were younger. As you get older, these areas with excessive sun exposure then, in effect, come due with the development of a new skin cancer lesion.
Bottom line? If you’ve had a previous skin cancer of any sort, we need to see you at least once a year at Advanced Laser and Skin Cancer Center. If you’ve had more than a single skin cancer, you should make those visits twice each year.
Is Mohs surgery painful?
Occasionally, when a patient hears we perform Mohs surgery using only local anesthesia, they assume there is pain involved. This is in no way the case. Modern local anesthesia is so effective that you can be sure you won’t feel anything as we excise the lesion and the surrounding tissue. We perform Mohs with you under only local anesthetic because if your sample shows there is still more cancer at one of the margins, we will need to take more tissue. If you’re only under local anesthesia, it’s easy to simply inject more anesthesia for the second procedure. That’s definitively not the case with general anesthesia. You cannot have general anesthesia twice in a single day, and it would be dangerous to keep you “under” for the time your sample is tested.
What kinds of skin cancer can Mohs surgery be used to remove?
Mohs surgery is far and away the best option for treating most basal cell carcinomas and squamous cell carcinomas. This is especially true if your lesions are in cosmetically and functionally important areas around your eyes, nose, lips, ears, scalp, fingers, toes, or genitals. Mohs is also recommended for basal cell and squamous cell cancers that are large, aggressive or growing rapidly, that have indistinct edges, or have recurred after previous treatment.
Mohs can be used for melanoma on the face. In these cases, the patient usually is first put on a course of a medication call Aldara (imiquimod), as this can make the body’s immune system first attack and remove stray melanoma cells outside the main lesion.
In larger melanomas on other areas, traditional same-day Mohs is not usually the path taken. In some cases, we may excise the lesion and leave the wound open but covered with sterile bandaging as the sample is tested. The patient returns home. The patient may need to return the next day to have a wider margin removed. Or if all the cancer is gone, the patient will return and the wound will be sutured closed. This is known as “slow Mohs.”
What happens if I don’t opt for Mohs surgery for skin cancer?
There are two main benefits to having us use Mohs methods to remove your basal cell or squamous cell carcinomas, along with many melanomas. First, this method ensures your cancer will be fully removed. As mentioned above, Mohs has over a 99 percent cure rate.
Second, Mohs guarantees Dr. Ragi and the rest of our team will only remove the minimum amount of skin necessary to remove the skin cancer. That’s because Mohs is performed in stages, with each removed sample being tested, until the sample is clear of all cancerous cells. With traditional skin cancer removal, doctors must take a larger area around the lesion to hopefully remove all the cancer cells. This takes more healthy, cancer-free skin than with Mohs methods.
By opting to have your skin cancer removed by, say, your dermatologist who is not trained in Mohs protocols, you’re rolling the dice on whether he or she gets all of the cancer cells. To do so, they will also probably need to take a larger amount of tissue than if Mohs methods were employed.
What do I need to avoid after my Mohs procedure?
You’ll want to avoid anything that places stress on your incision and its sutures. You will need to limit strenuous physical activity, excessive bending over, or other lifting for seven days after your Mohs surgery to allow your wound to heal and prevent bleeding or damage to your stitches. Since many of these procedures are performed on the face, you wouldn’t want to increase blood pressure to your facial area until you have healed sufficiently. We will usually remove your sutures from 5 to 10 days after your surgery.
We will give you detailed instructions of how to care for your incision.