Mohs Micrographic Surgery is
a specialized procedure for the removal of skin cancer. The procedure
is named after the originator of the technique, Dr. Frederick Mohs.
This information packet was written to help you understand what Mohs
Micrographic Surgery is, and why it is recommended for the treatment
of skin cancer.
Rhett Drugge, M.D., is board certified as a dermatologist
by the American Board of Dermatology and Dermatologic Surgery and is
a fellow of the American Society for Mohs Surgery.
Dr. Drugge is one of a very small number of specially
trained dermatologists who performs Mohs Micrographic Surgery in this
region. This highly successful surgery is offered in an outpatient setting
at the dermatology office of Dr. Charles Sheard and Dr. Rhett Drugge
on 50 Glenbrook Road in Stamford, Connecticut. Patients who undergo
Mohs Micrographic Surgery do so in relative comfort and do not require
a hospital visit.
Dr. Drugge encourages patients to be as informed as possible
about the surgical procedure they are considering. He and his staff
are available to answer any questions you might have.
What is skin cancer?
Skin cancer, by far the most common malignant tumor in
humans, is an abnormal growth of cells that expands in an unpredictable
pattern on the skin. The most common types of skin cancer are basal
cell carcinoma, squamous cell carcinoma, and malignant melanoma- each
named for the particular skin cell from which it arises. Basal cell
carcinomas and squamous cell carcinomas are commonly treatedby Mohs
Micrographic Surgery in our office. Other types of skin cancer can also
be treated with Mohs Micrographic Surgery.
Both basal cell carcinoma and squamous cell carcinoma
begin as a single point in the upper layers of the skin and slowly enlarge,
spreading both along the surface and downward. These extensions cannot
always be directly seen. The tumor often extends far beneath the surface
of the skin. If not completely removed, both types of skin cancer may
invade and destroy structures in their path.
Although these skin cancers are locally destructive, they
do not metastasize (spread) to distant parts of the body. Metastasis
is extremely rare in basal cell carcinoma and usually occurs only with
long-standing, large tumors. Squamous cell carcinoma is slightly more
dangerous and patients must be observed for any spread of the tumor,
although it is unlikely. Certain types of melanoma are treated by Mohs
Micrographic Surgery in our facility.
What causes skin cancer?
Excessive exposure to sunlight is the single most
important factor associated with the development of skin cancers. In
addition, the tendency to develop these cancers appears hereditary in
certain ethnic groups, especially those with fair complexions and poor
tanning abilities. Fair-skinned people develop skin cancers more frequently
than dark-skinned people and the more sun exposure they receive, the
more likely they are to develop a skin cancer. Other factors, including
exposure to certain chemicals, may also be involved in the development
of skin cancers. But the highest incidence of skin cancer is found in
cities such as Dallas and Miami where the sun is very intense.
How is skin cancer treated?
There are several methods for treating skin cancers,
including excision (surgical removal), curettage and electrodesiccation
(scraping and burning), X-ray therapy, cryosurgery (freezing), topical
chemotherapy and Mohs Micrographic Surgery. The method chosen depends
on the location of the cancer, its size, type, and previous treatment.
Your doctor will base his recommendations on these factors.
What is Mohs Micrographic Surgery?
Approximately 40 years ago, Dr. Frederick Mohs of Madison,
Wisconsin developed a unique treatment of skin cancer called chemosurgery.
Dr. Mohs applied a caustic chemical to "fix" (harden) the
area involving the area involving the tumor, so that it could be removed
and traced to all of its edges. Since then, the procedure has been refined.
Today, almost all cases are treated by the "fresh tissue"
technique which omits the use of this caustic chemical and allows dermatologists
to remove all of the tumor layers in one day. Mohs Micrographic Surgery
is a technique that enables dermatologists to selectively remove areas
involved with the skin cancer, while at the same time preserving the
greatest amount of normal tissue as is possible. If surgical repair
of the defect is necessary, it can be done with the knowledge that there
is no residual tumor left. As a result, Mohs Micrographic Surgery is
very, very useful for large tumors, tumors with indistinct borders,
tumors near vital functional or cosmetic structures and tumors for which
other forms of therapy have failed.
What will happen at my preoperative visit?
Your first visit allows the doctor an opportunity to examine
your skin cancer, obtain your medical history and determine whether
the technique of Mohs Micrographic Surgery is the most appropriate treatment.
It also gives you a chance to meet Dr. Drugge and his staff and learn
about the procedure. If you have been referred to the office, we will
usually have received a pathology report stating the type of skin cancer
you have. If this information has not been obtained, we will perform
a biopsy during your preoperative visit. This biopsy is important because
it will tell us what type of cancer you have - a critical factor in
planning your treatment. The date and time of your surgery will also
be scheduled at this consultation.
How should I prepare for surgery?
Eat your usual breakfast. If you normally skip breakfast,
please have a morning snack on the day of surgery.
Take all of your regular medications unless directed otherwise
by your surgeon or your regular physician. If you take any medicine
containing aspirin, salicylates, other pain medicine, anti-inflammatory
medicine or arthritis medicine, please discuss this with Dr. Drugge.
Wear comfortable, loose-fitting clothing that you can
easily get into and out of. Avoid any pull-over clothing. If necessary,
we may give you a hospital gown to wear during your surgery. You may
also want to bring a sweater in case the clinic room is air-conditioned.
Please leave your whole day available for surgery. That
will allow enough time for you to rest and recover from the procedure.
On the day of your surgery, we encourage you to bringa close friend
or relative with you who can help you drive home and keep you company
between each stage of the procedure.
If you are very anxious or nervous, we can give you a
mild sedative prior to surgery. This must be arranged prior to the day
of surgery. If you take a sedative, you must be accompanied by a close
friend or relative who can take you home after your surgery.
How is surgery performed?
Mohs Micrographic Surgery is performed in a procedure
room under sterile conditions, with local anesthesia. Once anesthesia
is complete, the visible portion of the tumor is removed by excision
or scraping with a sharp instrument called a curette. Following the
removal of most of the tumor, a thin layer, encompassing the complete
undersurface of the tumor, is excised. That layer is then cut into small
pieces and a map is drawn to identify the location of each piece. The
edges of each piece are marked with dyes to aid in orientation on our
map. Each piece is then frozen and these slices cut, stained, and examined
under the microscope. Any areas in which the tumor is found are marked
on the map. Regions with remaining tumor tissue are then reexcised.
This procedure is repeated until no more tumor is found and the cancer
is entirely removed. After each layer of tissue is obtained, oozing
or bleeding vessels are cauterized or ligated with a suture. A pressure
dressing is applied. You may then rest in a specially equipped waiting
area with your family member or friend.
How long does it take?
It takes 30 minutes to remove each layer of tissue, and
one or two hours to process and examine it. Most tumors require the
removal of three layers. Extensive tumors may need more surgery and
may require a second visit.
Will Mohs Micrographic Surgery cure me?
If you have a basal cell carcinoma, there is about a 99
percent chance that you will be cured. If you have a squamous cell skin
cancer, you can be about 95 percent certain that you will be cured by
Mohs Micrographic Surgery. However, follow-up visits to detect the rare
recurrence are very important. After the initial postoperative period,
you will return to your referring physician for routine skin care and
tumor surveillance. The Mohs surgeon will see you about once each year
for five years to rule out the possibility of recurrence.
When will my post-surgical plan be developed?
Since it is not possible to know the exact size of each
skin cancer until it has been completely removed, we cannot determine
your post-surgical treatment entirely in advance, although we can tell
you what to expect. Many wounds are superficial and can heal on their
own with excellent cosmetic results. If a surgical wound requires surgical
reconstruction, we will discuss it with you following the complete removal
of the cancer. Appropriate recommendations and referrals will be made
at that time.
What can I expect after the surgery?
You surgical wound will likely require special care during
the week(s) following surgery. You will have some swelling and redness
around the wound. This will gradually disappear over seven to ten days.
In larger wounds, some drainage may occur andmay have a foul odor for
a few days. You should plan on wearing a dressing and avoid strenuous
physical activity for one to two weeks.
You may experience a sensation of tightness across the
area of surgery. Skin cancers frequently involve nerves, and months
may pass before your skin sensation returns to normal. In some cases,
numbness may be permanent. You may also experience itching after your
wound has healed. Complete healing of the surgical scar takes place
over 12 to 18 months. Especially during the first few months, the site
may feel swollen or lumpy and there may be some redness. Gently massage
the area (starting about one month after surgery) and keep the area
lubricated with lotion to speed the healing process.
Bleeding is rare. If it occurs, have someone apply firm
pressure to the site. If a bulky dressing has been placed on the wound,
this should not be removed. Direct pressure should be applied to the
padded wound for 15 minutes, timed by watching a clock. Do not discontinue
pressure to see if the bleeding has stopped until 15 minutes have elapsed.
If the bleeding continues, continue to press directly with an additional
clean gauze pad over the bleeding site for another 15 minutes. If bleeding
continues, call our office or go to your local emergency room.
Mild to moderate pain is normal for a day or two
following surgery, but it generally responds well to oral pain medications
such as Tylenol or Tylenol #3. Do not
use aspirin or anti-arthritis pain medications such as Motrin or Advil
(ibuprofen) because they can cause bleeding. If regular pain medications
provide insufficient relief, or if the pain increases after 3 to 4 days,
you should contact our office.
How will my wound heal?
The human body healed itself naturally for thousands of
years before the advent of modern medicine, and it has great recuperative
ability. After the complete removal of the tumor, several options may
be considered for managing the wound.
Healing by spontaneous granulation
Letting the wound heal by itself offers a good chance
to observe the healing process and decreases the chance of a recurrent
cancer being invisible or hidden. If at any time during the course of
healing, the scar is deemed to be unacceptable, a cosmetic surgical
procedure can be performed. Allowing wounds to heal this way is relatively
painless and offers excellent cosmetic results for many body locations.
Closing the wound or part of the wound with stitches
This procedure often speeds healing and can offer good
cosmetic results, especially when the scar can be hidden in a line of
facial expression or wrinkling. Sutures generally remain in place for
5 to 7 days, and occasionally up to two weeks, depending on the location.
Do not bathe the area for the first 72 hours. On the fourth day following
surgery, you may shower, but you must avoid bathtubs and swimming pools
for 5 to 7 days.
Closing the wound with skin grafts, flap repairs
or other reconstructive procedures
Recommendations or referrals for these procedures will
be made after complete removal of the tumor. We will make recommendations
that best serve each patient's needs.
How should I care for my wound?
You can act as your own nurse and will be impressed
at the excellent job you can do. To facilitate the healing of your wound,
you must change the dressing daily. With proper care you will be surprised
and please at how well and rapidly your wound heals. The following materials
may be required, but should not be purchased before you receive your
- A bottle of peroxide for medicinal use (3%)
- Q-tips or cotton applicator sticks
- Non-stick dressing pads (Telfa)
- Hypoallergenic paper tape
- An antibiotic ointment such as Polysporin of Bacitracin
How do I change the dressing?
Keeping the dressing fresh and clean will facilitate healing.
Follow these steps:
- Remove the old dressing.
- Take a cotton-tipped applicator
and dip it into the hydrogen peroxide.
- Remove all crusting from the normal
skin. This may take some gentle, but persistent rubbing.
- Soak a cotton-tipped applicator
in hydrogen peroxide. Then clean the bottom of your wound if the wound
has been allowed to heal on its own, by gently rolling, not rubbing,
with the Q-tip. It may take 6 - 10 different applicator sticks to
adequately clean the area.
Note: Never place a used applicator stick back into the bottle of
- Apply antibiotic generously to the wound.
- Cut the non-stick dressing to fit the exact size of
the base of the wound, then place it onto the base. If the wound has
been sutured, the non-stick dressing should cover the ewn area completely.
- Cut a gauze pad to the size of the wound and place
it over the non-stick dressing.
- Use hypoallergenic tape to hold the dressing in place.
- If the wound is near the eye, plain water should be
used for cleaning the wound since hydrogen peroxide may cause irritation
if it gets into the eye. If you have any problems or further questions,
please call our office.
- If you will require any modifications of this dressing
procedure, we will inform you and supply you with the materials at
the time of surgery.
- Do advise us as soon as possible if you must cancel
or change your appointment.
- Do get a good night's sleep prior to surgery.
- Do take your usual medications on schedule, unless
otherwise directed by your doctor.
- Do take any new medications your Mohs surgeon prescribes
- Do eat breakfast.
- Do consider bringing someone with you or arrange to
have someone drive you home.
- Do ask any questions you might have.
- Do not consume alcohol for 24 hours prior to or 48
hours after surgery.
- Do not engage in strenuous physical activity for 24
hours prior to surgery. Discuss with your doctor when you may resume
We want you to be as comfortable, relaxed and informed
about your Mohs Micrographic surgery as possible. Please call us at
(203)324-5719 us if you have any questions.