Physicians in the Skin Surgery and Oncology Service of the Department of Dermatology at UT Southwestern Medical Center specialize in delivering comprehensive care to patients diagnosed with skin cancer.
A primary focus of the service is "Mohs surgery", a form of cancer treatment which is highly effective in removing common skin cancers, including basal cell carcinoma, squamous cell carcinoma, some forms of melanoma and a variety of other more rare skin cancers. (Malignant melanoma, is typically treated in the Clinical Center for Malignant Melanoma by means other than Mohs surgery.)
This brochure is designed to explain how Mohs surgery is performed, how you as a patient can prepare for surgery, what to watch for following surgery, and how to protect yourself from developing skin cancers in the future.
Table of Contents
What is Mohs surgery? Named after the surgeon who developed the technique in the late 1930's, Mohs surgery is an outpatient form of excisional surgery which can effectively remove most skin cancers one layer at a time. After each layer is removed, it is examined under a microscope to determine whether residual cancer remains in the patient's skin and, if present, determine the location.
The benefits of Mohs surgery: It is a highly effective means of treating common skin cancers with a success rate for the treatment of primary (never treated) basal cell carcinomas that approaches 99%. When used to treat basal cell carcinomas which have come back (recurred), the success rate averages about 95% (when methods other than Mohs surgery produce an average cure rate of 80%).
It is best used to treat skin cancers occuring in and around the face because cancers in the location can dive deep along tissue planes beneath the skin's surface. Mohs surgery provides an effective means of removing these "roots" which can produce recurrances if not eradicated. The patient does not have to be put to sleep and the procedure can by performed in a doctor's office; usually within one day. Use of a microscope allows the surgeon to be precise, thereby preserving as much normal tissue as possible while optimizing the chance for cure.
How is Mohs surgery performed? First, the area involved with cancer is numbed with the injection of a local anesthetic to eliminate pain. This is usually the only painful part of the procedure. We will use a number of techniques to minimize the pain of administering local anesthesia. Using a sharp curved instrument, the cancerous lesion is carefully scraped so that the margins of the lesion are well defined. During this procedure you may feel some pressure but should not feel any pain. A 1 to 3 mm margin of tissue is marked beyond the scraped area. Then the lesion is removed along with the thin tissue margin, which surrounds the lesion on the sides and underneath.
The tissue is then carefully divided into pieces and their edges marked and color coded with special dyes. A careful "map" is made of the treatment area corresponding to the color code used on the removed tissue. The tissue is taken to our laboratory where it is rapidly frozen, cut into thin sections, placed on microscope slides, and stained. Using the microscope, the surgeon determines whether any tumor persists. If an edge of the wound still contains tumor, it is noted on your patient map.
Bleeding - Some post-operative bleeding occurs in a small number of patients and can usually be controlled by staying calm and the application of direct pressure on the wound. If bleeding persists after applying constant pressure to the bleeding point with a gauze pad for 15 to 30 minutes, then medical assistance may be required. Bleeding to this extent is rare, but if assistance is required, you should call our clinic or visit a local emergency room.
The removal and preparation of tissue takes approximately 1 to 2 hours for each layer. You spend only 5 to 30 minutes of that time in the surgical suite. The remainder of time is required for tissue processing and evaluation. The average patient requires 2 to 3 stages for complete removal of the tumor. Therefore, by beginning early in the morning, Mohs surgery is generally completed in one day. However, extensive disease may be encountered and may require continued surgery on a following day.
Repair surgery: Once all the skin cancer cells have been removed, you will be left with a surgical wound. Several options will be available for repair of this wound. The options will be discussed with you, and we will recommend the one that can restore as much function as possible to affected structures and provide the best cosmetic result.
Repair surgery options: Spontaneous granulation - Skin tissues have a remarkable capacity to heal themselves and experience has taught us that certain areas of the body will heal themselves very nicely, thus requiring no further surgery. This type of healing also allows observation of the wound when a difficult tumor is involved and recurrence is a consideration. At other times, wounds should be left to heal on their own with plans to, at a later date, use reconstructive surgery to treat the resulting scar.
Closing side-to-side with stitches - Excellent cosmetic results can often be obtained by simply stitching the skin edges together with sutures. This approach usually requires additional skin and tissue to be removed in order for the final scar to lay flat. This technique is best used on small defects and when the scar can be hidden in a wrinkle line.
Skin graft - Grafting involves covering the wound with the skin obtained from other parts of the body. Split-thickness skin grafts are thin shavings of skin usually obtained from the thigh. This can be used as permanent coverage or as temporary coverage prior to the final reconstructive cosmetic procedure. Full-thickness skin grafts require a thicker layer of skin and are usually used as permanent coverage. Skin around the ear or collar bone is removed and stitched to cover the wound. The donor site is then sutured together.
Skin flaps - Skins flaps involve the movement of nearby or adjacent healthy skin to cover the surgical wound. This form of closure often provides excellent cosmetic results due to the match of skin texture, consistency, and color.
Consultation with another reconstructive surgeon - If prior to your Mohs surgery it is determined that your surgery may prove to be extensive or involve significant functional impairment, we will seek the help of one or more consulting physicians for reconstruction of the surgical defect. We may notify these surgeons that their services may be required and they will then notify you of additional special instructions to prepare you for your surgery. You will see one of these physicians either before or on the day that the Mohs surgery is performed. They would perform the reconstructive surgery either the same day as the Mohs surgery or within several days following the Mohs surgery.
Patient preparation for surgery: We like to see all patients in a preoperative consultation to discuss surgery. This can occur the same day that your surgery is scheduled. During this visit we will address the issues surrounding your surgery, introduce you to the surgical team, and answer any questions you might have. If a biopsy has not been performed prior to this visit, it will be performed at this time.
Please try to get a good night's sleep followed by breakfast, unless you are specifically told not to eat or drink after midnight the night before surgery. Be prepared to spend the entire day with us and bring reading material or a companion to converse with. The day can also be quite tiring. It is important to have someone provide you a ride home once surgery is completed.
Most insurance carriers cover the cost of Mohs and repair surgery. You can facilitate the process by being prepared to provide your insurance information to our billing office and by bringing with you the necessary forms for processing.
What to look for after surgery: Pain - Most patients are surprised at how little pain they experience following surgery. If you do have discomfort, we request that you use Tylenol and avoid aspirin. If a more powerful pain reliever is needed, this can be prescribed for you.
Bleeding - Some post-operative bleeding occurs in a small number of patients and can usually be controlled with the use of pressure. If bleeding persists after applying constant pressure to the bleeding point with a gauze pad for 15 to 30 minutes, then medical assistance may be required. Bleeding to this extent is rare, but if assistance is required, you should call our clinic or visit a local emergency room.
Swelling and bruising - Both are commonly seen following Mohs surgery, particularly when treating lesions around the eyes and mouth. The application of ice packs for the first 24 hours following surgery often helps to minimize these problems. Otherwise, swelling and bruising normally subside within 4 to 7 days following surgery.
Infection - Most wounds develop redness at the edges as a normal part of healing. However, if the redness does not subside after several days or if warmth, pain, or pus are noted, you should immediately notify us or your physician.
Itching and Redness - Reactions to tape are common and can produce itching and redness. If this occurs, you can request a non-allergenic tape at your local pharmacy and make us aware of your problem on your return visit.
Numbness - Cutting into the skin damages nerve endings which can lead to varying degrees of numbness at and around the surgery site. This numbness may persist for months or longer and in some instances may be permanent. Often other sensation changes are noted and persist through the first year following surgery, usually representing the regeneration of nerve fibers.
Scar - Although every effort will be made to offer the best possible cosmetic result, you will be left with a scar. The scar may be minimized by proper wound care. We will discuss wound care in detail with you and give you wound care instructions to take home following surgery.
Skin cancer prevention: Sunscreen - There is no need to completely avoid the sun, however, you should develop a habit of applying a good sunscreen at least 10 minutes before sun exposure. We recommend the use of a No. 15 strength or higher with reapplication after swimming or heavy perspiration.
Protective clothing - A wide brimmed hat, long sleeved shirt, and other protective clothing should be used when at all possible. We recommend avoiding excessive sunshine (particularly between 10:00 a.m. and 3:00 p.m.), sunbathing, and suntanning booths.
Personal skin exam - You should get in the habit of inspecting your entire skin surface including the scalp, on a monthly basis. A full length mirror, good lighting, and the assistance of a family member are necessary to adequately examine your back and other hard-to-see areas. If you notice any changes in your skin or lesions which look suspicious to you, bring this to the attention of your dermatologist immediately.
Evaluation by a dermatologist - A careful skin exam with care taken to look for skin cancer recurrence should be performed by a qualified physician, such as your dermatologist, at 6 to 12 month intervals. After your wound has healed (usually 1 to 2 months), we request that you continue to be followed by your referring physician.
For consultation and referral: For further information on the Skin Surgery and Oncology Service at UT Southwestern or to make an appointment, please call (214) 645-8950 for assistance.
Dermatology Surgery Physicians:
Jennifer Perone, MD - Assistant Professor
Stan Taylor, MD - Professor, Director - Skin Surgery & Oncology Clinic
Sarah Weitzul, MD - Assistant Professor, Director - Clinical Center for Cosmetic Dermatology
Erin M. Welch, MD - Assistant Professor
**all UTSW Dermatology Surgery Physicians are board certified by the American Board of Dermatology
