Paul Friedman, MD

Houston Office: 713-900-3900

New York Office: 917-745-5029

Mohs Micrographic Surgery

Skin Cancer Treatment

About Mohs Surgery

Mohs surgery has been shown to be a highly effective treatment for certain types of skin cancer, with a cure rate of up to 99% for certain tumors. Due to the fact that the Mohs procedure is micrographically controlled, it provides the most precise method for removal of the cancerous tissue, while sparing the greatest amount of healthy tissue. For this reason, Mohs surgery may result in a significantly smaller surgical defect and less noticeable scarring, as compared to other methods of skin cancer treatment. The Mohs procedure is recommended for skin cancer removal in anatomic areas where maximum preservation of healthy tissue is desirable for cosmetic and functional purposes. It may also be indicated for lesions that have recurred following prior treatment, or for lesions which have the greatest likelihood of recurrence.

Click for risks of Mohs Microscopic Surgery

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About the American College of Mohs Micrographic Surgery and Cutaneous Oncology

The American College of Mohs Micrographic Surgery and Cutaneous Oncology is the premiere institute of dermatologists, pathologists, and Mohs technicians. Founded in 1967, Mohs College is dedicated to the highest quality patient care and education relative to Mohs surgery as a specialized surgical treatment for skin cancer.

Click here for brochure on Mohs Surgery Information.

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Preoperative Visit

If you would feel more comfortable meeting Dr. Friedman and his staff, we welcome the opportunity for a preoperative consultation. However, if you feel comfortable with the explanation provided here and your referring doctor, feel free to schedule your surgery directly. If you take Coumadin or blood pressure medications or if you normally take an antibiotic prior to dental work, please bring this to our attention so that there is no delay in your surgery.

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Before Mohs Micrographic Surgery

Be well rested and eat a good breakfast. Take your usual medications, unless directed otherwise. We request that you do not take any aspirin or aspirin containing products, such as Anacin or Bufferin, for ten days prior to the surgery. In addition, please do not take Ibuprofen (Motrin, Advil, etc.). These medications may “thin” your blood and cause more bleeding. You may substitute acetaminophen (Tylenol) if required. Do not drink any alcoholic beverages for 24 hours before surgery.

If you have been advised in the past to take antibiotics before a surgical procedure, such as dental work, please adhere to the prescription instructions before your Mohs surgery appointment.

Shampoo your hair the night before surgery, as your wound and initial dressing may have to remain dry for 24 hours thereafter. The length of the procedure varies depending on the size and location of the skin cancer and the type of reconstruction to be done. Although the average length of time is 2-4 hours, you should plan on spending much of the day in our office. We ask that you limit the number of people accompanying you to one because of the limited space in our waiting room. There is plenty of time spent waiting for the lab work, so bring a book or something to keep busy.

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The Day of Skin Cancer Surgery

Appointments for surgery are scheduled throughout the day. It is a good idea to wear loose fitting clothing and avoid “pullover” clothing. Also, if the operative site is on the face, please do not wear make-up on or around the area. We will obtain your written consent for the procedure, photographs will be taken, and your blood pressure will be recorded. If you have any additional questions, please feel free to ask them at this time.

The area surrounding the skin cancer will be cleansed with an anti-bacterial soap. The doctor will then anesthetize (numb) the area of skin containing the cancer by a small local injection. This injection will probably be similar to the one you received for your biopsy. We will be as gentle as we can when administering this. It usually takes 15 minutes to anesthetize the involved area and remove the tissue. After the tissue has been removed, it will be processed in our office laboratory.

Depending upon the amount of tissue removed, processing usually takes an additional 30-45 minutes. Your wound will be bandaged, and you will move to the waiting room while the tissue is processed for examination, stained, and examined by Dr. Friedman. If the microscopic examination of the removed tissue reveals the presence of additional tumor, we will go back and remove more tissue. The Mohs technique allows us to precisely map out where the roots of the cancer remain. Most skin cancers are removed in 1-3 surgical stages.

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Reconstruction

After the skin cancer has been completely removed, a decision is made on the best method for treating the wound created by the surgery. These methods include letting the wound heal by itself, closing the wound in a side to side fashion with stitches, closing the wound with a skin graft or a flap. In most cases, the best method is determined on an individual basis after the final defect is known. Most of the wound closures are performed in our office. However, other surgical specialists may be utilized for their unique skills if a tumor turns out to be much larger than initially anticipated. We individualize your treatment to achieve the best results.

When the reconstruction is completed by other surgical specialists, that reconstruction may take place on the same day or on a subsequent day. There is no harm in delaying the reconstruction for several days. If the reconstruction is to be extensive, that portion of the operation may require hospitalization. This is the exception rather than the rule as most wounds are repaired immediately in our office while the site is still anesthetized.

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After Mohs Micrographic Surgery

Your surgical wound will likely require care during the weeks following surgery. Detailed written instructions will be provided. You should plan on wearing a bandage and avoiding strenuous physical activity for a week. Most of our patients report minimal pain which responds readily to Tylenol. 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 rare instances, the numbness may be permanent. You may also experience itching after your wound has healed. Complete healing of the surgical scar takes place over 12-18 months. Especially during the first few months, the site may feel “thick,” swollen, or lumpy, and there may be some redness. Gentle massage of the area (starting about 1 month after the surgery) will speed the healing process.

An indefinite follow-up period of observation is necessary after the wound has healed. You will be asked to return in six weeks, six months, and one year following the procedure. Studies have also shown that once you develop a skin cancer, there is a strong possibility of developing other skin cancers in the future. Should you notice any suspicious areas, it is best to check with your physician for a complete evaluation. You will be reminded to return to your dermatologist on a frequent basis for continued surveillance of your skin.

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Risks of Mohs Microscopic Surgery

Because each patient is unique, it is impossible to discuss all the possible complications and risks in this format. The usual risks are discussed below. Dr. Friedman will discuss any additional problems associated with your particular case. Please understand that these occurrences are the exception and not the rule.

The defect created by the removal of the skin cancer may be larger than anticipated. There is no way to predict prior to surgery the exact size of the final defect.

There will be a scar at the site of the removal. We will make every effort to obtain optimal cosmetic results, but our primary goal is to remove the entire tumor. Again, Mohs surgery will leave you with the smallest wound thus creating the best opportunity for optimal cosmetic results.

There may be poor wound healing. At times, despite our best efforts, for various reasons (such as bleeding, poor physical condition, smoking, diabetes, or other diseases), healing is slow or the wound may reopen. Flaps and grafts utilized to repair the defect may at times fail. Under these circumstances, the wound will usually be left to heal on its own.

There may be a loss of motor (muscle) or sensory (feeling) nerve function. Rarely, the tumor invades nerve fibers. When this is the case, the nerves must be removed along with the tumor. Prior to your surgery, the doctor will discuss with you any major nerves which might be near your tumor.

The tumor may involve an important structure. Many are near or on vital structures such as the eyelids, nose or lips. If the tumor involves these structures, portions of them may have to be removed with resulting cosmetic or functional deformities. Furthermore, repairing the resulting defect may involve some of these structures.

Rarely, wounds become infected (fewer than 1%) and require antibiotic treatment. If you are at particular risk for infection, you may be given an antibiotic prior to surgery.

There may be excessive bleeding from the wound. Such bleeding can usually be controlled during surgery. There may also be bleeding after surgery. We have never had a significant amount of blood loss, but bleeding into a sutured graft or flap may inhibit good wound healing.

There may be an adverse reaction to medications used. We will carefully screen you for any history of problems with medications; however, new reactions to medications may occur.

There is a small chance that your tumor may regrow after surgery. Previously treated tumors and large, longstanding tumors have the greatest chance for recurrence.

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