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What Is Mohs Skin Cancer Surgery

Five Things To Know About Mohs Surgery For Skin Cancer

Mohs Skin Cancer Surgery Explained

Ian Maher, MD, just wants to make things quick and easy for skin cancer patients.

Maher is a dermatologic surgeon with University of Minnesota Health and an associate professor in the University of Minnesota Medical Schools Department of Dermatology. He is an expert in Mohs surgery, a surgical technique that treats skin cancer by gradually removing thin layers of skin from a skin cancer site until a patient is cancer free. Unlike other skin cancer surgeries, Mohs surgery can be completed in just a day with same-day testing that gives patients greater peace of mind. The procedure is essentially painless and is highly effective. It can be used to treat basal cell carcinoma and squamous cell carcinoma, in addition to melanoma.

A West Virginia native, Maher also treats other complex skin tumors and performs reconstructive operations after skin cancer surgery. Maher is considered a national expert on post-skin cancer reconstruction, lectures extensively at national meetings and is the author of over 40 peer-reviewed publications and a dozen book chapters. We caught up with Maher to talk about five things we should know about Mohs surgery.

What Is Mohs Surgery For Skin Cancer

People with skin cancer on their face, head, neck, hands feet or genitalia might be good candidates for Mohs surgery. Its different from standard surgery for skin cancer, and its important that it be performed by a surgeon specially trained in the procedure, following the pre-described steps to ensure the best outcomes.

With standard surgery, you cut out the cancerous area and the patient goes home. The specimen will be sent off to a pathologist, and the pathologist will check the margins of the sample to see if the edges are clear and free of cancerous cells, explains Kimberly Brady, MD, of the Department of Dermatology at Roswell Park Comprehensive Cancer Center. The pathologist can take only a representative sample through whats called bread loafing taking a few pieces and looking at whether the edges are cancer-free. If they are, they can be confident the tumor was removed.

That process takes time and can involve multiple visits back to the hospital or doctors office to make sure the cancer cells have been eliminated. It also increases the risk that residual cancer cells could remain, leading to recurrences later.

Why Is Mohs Surgery Performed

Mohs surgery commonly addresses skin cancer that:

  • Is located on any sensitive area where it is important to minimize the removal of normal healthy tissue, such as the head and neck, fingers, toes or genitals

  • Is of an aggressive subtype

  • Develops in patients with suppressed immune systems

  • Was previously treated and has come back

  • Is growing quickly

  • Is large

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What Is The Procedure For Mohs Surgery

  • This is an outpatient procedure, which means that the patient can go home on the same day of the surgery.
  • The area of operation is first cleaned.
  • The doctor injects the operation area with local anesthesia, which numbs the area and prevents any discomfort during the procedure.
  • The surgeon removes the visible part of cancer along with an underlying, thin layer of tissue slightly larger than the tumor that is visible using a scalpel or surgical blade.
  • A temporary bandage is put on the incision area.
  • The excised tissue is sent to the laboratory for analysis.
  • The patient needs to wait in the waiting room, while the excised tissue is cut into different sections and examined under the microscope.
  • The exact spot of each part of the tissue removed is marked by the surgeon by making a map. This helps the surgeon in knowing precisely in which part to continue the surgery.
  • If cancer still remains, Mohs surgery will continue. The surgeon then removes an additional tissue layer from the affected area, while leaving as much healthy tissue as possible intact.
  • The tissue removed is again examined in the laboratory, while the patient is made to wait for the results.
  • The procedure is repeated till the last tissue sample removed is free of cancer.
  • Local anesthesia may be re-injected or required.

Mohs Micrographic Surgery For Skin Cancer

Mohs Micrographic Surgery

Mohs micrographic surgery is also called margin controlled excision. It is a specialist type of surgery that aims to remove all the skin cancer and leave as much healthy skin tissue as possible.

As it is a specialised type of surgery, your doctor might refer you to another hospital to have the treatment.

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How Does Mohs Micrographic Surgery Work

The procedure is done in stages. After the affected area has been numbed with local anesthesia, the doctor uses a scalpel to excise the cancer in a disklike shape, says Dr. Leffell. When using the standard technique of simple excision, the surgeon must remove the tumor and cut a wide margin around it to ensure that she is removing as many of the abnormal cells as possible.

But with Mohs surgery, the doctor can start with a narrower excision and use a scalpel to remove just what is visible and can then later remove more if necessary.

The specimen is then brought to a laboratory that is a part of the Mohs unit. The specimen is divided into pieces and carefully mapped using different colors of ink. The tissue pieces are then processed in the lab and studied under the microscope by the Mohs surgeon, who can check the margins around the edges and underneath the tumor. Then the surgeon returns to the patient and removes another layer of cancerous tissue, if needed. In about 50 percent of cases, only one layer is needed to clear the cancer.

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Mohs Micrographic Surgery Is The Most Modern Accurate And Most Highly Specialized Treatment For The Total Removal Of Skin Cancer

Mohs micrographic surgery has set a new standard in skin cancer treatment. An increasing number of physicians are performing Mohs surgery, which is now widely accepted as the most effective treatment for most types of skin cancer. However, not all Mohs surgeons receive the same level of training as Dr. Robert Griego and Dr. Daniel Skinner, both of whom are fellowship-trained Mohs surgeons.

When it comes to your skin cancer treatment, you deserve no less than the best. Both Dr. Griego and Dr. Skinner have achieved the highest degree of Mohs surgery qualification by completing an American College of Mohs Surgery approved fellowship. Both Dr. Griego and Dr. Skinner are board-certified dermatologists with expertise in facial reconstruction after skin cancer removal. For you, this means peace of mind, knowing that you will receive superior quality and competency, as well as an optimal outcome.

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What Happens On The Day Of The Mohs Micrographic Skin Cancer Surgery

Your appointment will be scheduled early in the day. Our staff will escort you into a surgical suite where the micrographic surgeon will numb the area around the skin cancer. Once its numb, the visible cancer and a thin layer of tissue will be removed. This tissue is carefully mapped and coded by the surgeon and taken to the adjoining laboratory where the technician processes the microscope slides. You will have a temporary dressing placed over the wound and will be free to return to the waiting room.

The Mohs surgical procedure usually takes only 10-15 minutes. However, it takes a minimum of 1-2 hours in the laboratory to process and examine the tissue. You will be asked to wait in the waiting room while the laboratory work is being done. If remaining cancer is found, you will be brought back to the surgical suite and a second thin layer will be taken from that area. This will also be taken to the laboratory for processing while you wait. Although there is no way to tell before surgery how many stages will be needed, most skin cancers are removed in three stages or less.

Limitations Of Mohs Surgery

Mohs Surgery: The Most Effective Treatment for Skin Cancer

Mohs surgery is most successful in treating certain cutaneous neoplasms, and it can be used alone or in a multidisciplinary approach to achieve the highest possible cure rate for a variety of difficult-to-treat tumors. However, limitations of Mohs surgery may include the following:

  • Noncontiguous tumors and/or disconnected foci in tumors may result in recurrence.

  • Adjunctive therapy may be necessary to ensure cure.

  • The extent of the tumor may be too great to be amenable to surgery.

Mohs surgery is indicated for the treatment of skin tumors that primarily spread by direct extension . This procedure would not be appropriate for tumors that have satellitosis, a multicentric origin, or skip areas. However, routine surgical excision of such tumors also fails, often at the expense of excessive tissue sacrifice.

Mohs surgery may also be limited by the extent of the tumor. This procedure is indicated for special situations, such as tumors that are deeply penetrating or that have perineural invasion. If the tumor is so deeply invasive that it involves bone and/or vital structures, a multidisciplinary approach is indicated. For example, tumors that invade bone may need to be cleared peripherally using Mohs surgery an additional specialist, such as an otolaryngologist and/or head and neck surgeon, may be consulted to treat the deep component of the tumor.

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Mohs Surgery To Treat Skin Cancer On Nose

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Laser Therapy And Light Therapy For Skin Cancer

Advanced technology has great potential for enhancing the care of people with nonmelanoma skin cancer. Laser therapy and light therapy may provide effective noninvasive basal cell carcinoma treatment. At MSK, we have advanced expertise with all forms of laser and light therapy. This includes CO2 laser therapy, erbium laser therapy, and photodynamic therapy. We are also researching new noninvasive approaches to diagnose basal cell carcinoma and guide its treatment.

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Mohs Surgery Is On The Rise For Good Reasons: It Has The Lowest Recurrence Rates Highest Cure Rates And Best Cosmetic Results Of Any Skin Cancer Treatment A Physician Member Of The Skin Cancer Foundation Explains Why Mohs Has It All

Lifesaving new medications for people with advanced melanoma, called targeted therapies and immunotherapies, have grabbed the biggest skin cancer headlines in the past few years, and thats good news. But for people with the more common nonmelanoma skin cancers, basal cell and squamous cell carcinoma , an older technique has also been drawing more attention and favor than ever. I recently led the task force to establish consensus guidelines on the treatment of BCC and SCC, which were published this year. They demonstrate that Mohs surgery is the treatment of choice for many BCCs and SCCS, and the single most precise and effective method for eliminating these cancers.1-3

Did you know your chance of developing a nonmelanoma skin cancer in your lifetime is about one in five? More than 5.3 million cases of BCC and SCC are diagnosed in the U.S. each year. Exposure to ultraviolet light, either from the sun or from indoor tanning, is the greatest risk factor for developing these skin cancers, so its not surprising that approximately 80 percent of these cancers occur on the head and neck, where exposure is greatest. Unfortunately, since these are the most conspicuous skin cancers, they are also the most cosmetically challenging, capable of becoming disfiguring and sometimes dangerous if not caught at an early stage.

Thats why I want you to know just what Mohs surgery is, how it works, and what it can do to leave you cancer-free while looking the best you can after surgery.

Preparing For Your Surgery

Mohs Surgery and Skin Cancer Photos

You will need to be off for the entire day of your surgery, as we cannot predict how long you will be with us on that day.

What to Bring:

Please bring a book or a tablet to help pass the time. We have Wi-Fi available. Wear comfortable clothes that can be easily removed without going over your head such as a button-down shirt. We will provide light snacks throughout the day.


Only stop your medications if instructed by your primary care doctor or cardiologist. If you take aspirin for prevention and have NO history of heart attack or stroke, please stop your aspirin ten days before surgery. If you take ibuprofen or naproxen, please limit your use for two weeks prior to surgery. Please stop the following oral supplements one week prior to surgery: fish oil, garlic supplements, ginkgo, and vitamin E.

If you have been told by your doctor to take antibiotics before procedures and you have a history of artificial implants, heart valves, heart murmurs, or other conditions, please call our office prior to surgery so we can help you plan accordingly.

Day of Surgery:

Please eat breakfast and take your regular medications. You will be awake for the procedure so it is not necessary to fast.

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Is Mohs Right For Me

Mohs surgery is the gold standard for treating many basal cell carcinomas and squamous cell carcinomas , including those in cosmetically and functionally important areas around the eyes, nose, lips, ears, scalp, fingers, toes or genitals. Mohs is also recommended for BCCs or SCCs that are large, aggressive or growing rapidly, that have indistinct edges, or have recurred after previous treatment. Some surgeons are also successfully using Mohs surgery on certain cases of melanoma.

Can The Cancer Come Back

Mohs surgery has the highest cure rate of all treatments for basal cell and squamous cell carcinomas — more than 99% for new skin cancers and 95% if the cancer comes back.

Your doctor will want to schedule regular follow-ups with you to check your skin for new cancers. Twice a year is normal, but you may need them more often if the cancer is an aggressive type thatâs more likely to come back. You and your doctor will decide on the right schedule.

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Younger People Benefit Too

The number of people who develop skin cancer has been increasing for decades, and, alarmingly, more women and men under age 40 are now being diagnosed with the disease. Particularly in women, indoor tanning has been linked by many experts to an increased incidence of skin cancers at younger ages.

In my practice, I treat at least one patient in his or her 30s each week with Mohs surgery and many in their 40s and 50s, which is vastly different than 20 years ago, when the majority of patients were older. Not many young people seriously worry about getting skin cancer. Many use tanning beds and skip sun protection, and if they discover an unusual growth on their skin, they often delay seeking treatment because they think its no big deal. But it can be. Basal cell carcinomas rarely metastasize, or spread through the body, but some have aggressive growth patterns and can cause significant damage by growing along nerves or blood vessels, or through muscle or bone. By allowing the cancer to grow, you risk requiring more extensive surgery in the future. Squamous cell carcinomas can be more dangerous, carrying an approximately 4 percent risk of metastasis and 2 percent risk of death6, and the risk increases when these cancers return after treatment.

Arielle N.B. Kauvar, MD

Know That Surgery Sites Heal In Time

Mohs Surgery for Skin Cancer Treatment

Had basal cell on the side of my nose going toward the corner of my eye. Couldnt see anything on the skin, but thanks to the keen eye of my derm she saw it, and did a biopsy, and sent me to a Mohs specialist at UAB. He removed it along with surrounding tissue, sutured, sent me on my way looking, well, terrible! Within 1 year, the scare is completely gone & cant tell anything was done. Thankful for those yearly scans. Debbie

I had Mohs done on a very small spot on side of nose right by eye. They had to put me to sleep and did a flap on forehead. Also had Mohs on lip. It went about 2 inches outside of mouth and about an inch in mouth. Great results. Almost unnoticeable. Joy

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What To Expect From Your Mohs Surgery

Mohs Surgery: What to Expect on the Day of Surgery Before the Surgery. Since the surgery is performed under local anesthesia only, you wont have to make too many During the Surgery. Mohs surgery is performed in one day as an outpatient or ambulatory procedure, but takes place in After the Surgery. Your surgeon will determine the best method for reconstruction once More

What To Expect During Mohs Surgery

Use this infographic to learn what to expect during mohs surgery.

The visible tumor and a thin layer of surrounding skin are removed.

The tissue is examined under a microscope to see if any cancer cells remain at any of the edges.

If any cancer cells remain, additional skin is removed and examined under the microscope.

This process continues until no more cancer cells are found at the edges.

ImagesImage used with permission of Journal of the American Academy of Dermatology: J Am Acad Dermatol. 2007 57:832-5.

ReferencesNouri K, Patel AR, et al. Mohs micrographic surgery. In: Nouri K. Skin Cancer. The McGraw-Hill Companies, Inc., China, 2008:482-490.

Schaeffer M, Geisler A, et al. Patient-reported preferences associated with Mohs micrographic surgery of nonmelanoma skin cancer: Relative importance of factors pertaining to surgeons and staff during the perioperative course. Poster presented at: 74th Annual Meeting of the American Academy of Dermatology 2016 Mar 4-8 Washington, DC. Commercial support: None identified.

Stigall LE, Brodland DG, et al. The use of Mohs micrographic surgery for melanoma in situ of the trunk and proximal extremities. J Am Acad Dermatol. 2016 Nov 75:1015-121.

Walker E, Mann M, et al. Rapid visualization of nonmelanoma skin cancer. J Am Acad Dermatol. 2017 Feb 76:209-16.


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