Mohs surgery

Every year, about 10,000 new cases of skin cancer are diagnosed in Israel. Skin cancer might be the most common cancer in the world, but a large number of lesions are not life-threatening. These lesions grow locally. The reasons for their development vary, from prolonged exposure to the sun, having fair skin, genetics and weakened immune system.

If you or a close relative are dealing with skin cancer, you should check with your doctor if the Mohs surgery can be performed, which is considered the most advanced and effective surgical technique in the world for certain types of skin cancer.

What’s important to know about Mohs surgeries

Doctors all over the world use Mohs surgery (MOHS) for the effectiveness of the technique and the high rates of healing after using it, compared to other treatment options. Mohs surgery is especially effective in BCC type tumors (Basal cell carcinoma) and SCC (Squamous cell carcinoma).

The method is unique, which was developed in the 30s by Dr. Friedrich Mohs (Wisconsin University, USA), for it allows a microscopic test and immediate pathologic interpretation during the surgical procedure of all tumor tissues removed.

If the test indicates tumor residue in the depth or perimeter, it is removed on the spot. The method allows the complete removal of all roots and extensions of the tumor while preventing unnecessary resection of healthy tissue and minimal removal of skin.

In other words, in the Mohs surgery, 100% of the surgical tissue margins removed are tested in a special technique of flattening, freezing, cutting and painting, which allow discovery of cancerous roots that were not removed, to remove them and thus to prevent tumor recurrence.

Mohs surgery necessitates the use of an operating room with a special lab attached where a tissue test is performed in real-time.

Where is it appropriate to use the Mohs surgery

This surgical method is appropriate to treat:

• Tumors with unclear borders
• Tumors that came back after treatment/surgery
• Tumors that are known in advance to have a chance of recurrence
• Tumors located in areas (like facial skin) requiring maximal preservation of healthy skin for restoration, without creating esthetic flaws following the tumor’s resection.

Operate only with experts – it’s important that your surgeon will have the proper training in the pathology (dermatosurgery and histopathology) of the skin and has been trained in the Mohs surgery.

Preparation for the Mohs surgery

The more prepared you show up for the surgery, the more relaxed and under control you’ll feel. For that, we gathered for you general instructions for the surgery:

• You don’t need to fast on the surgery day since it is performed under localized anesthesia. Use this to have a good breakfast on surgery day.
• It’s recommended to bathe the evening and morning before the surgery. Women – don’t wear make-up if the surgery is on the face area.
• Chronic medications, like blood pressure, diabetes and so on, or prescription medications – continue taking normally unless you received other instructions.
• If you’re taking anticoagulants (Aspirin, Coumadin, Plavix, Pradaxa and more), consult with the doctor in advance regarding taking them before the surgery.
• Food supplements, such as: fish oil, omega 3, vitamin E and so on, recommended stopping taking a week before the surgery.
• Avoid smoking for 24 hours before the surgery.

What to bring with you to the hospital

1. A list of the regular medications you’re taking
2. ID or driver’s license
3. Letter from the family physician
4. If the patient has a pacemaker, it’s important to notify the doctor!
5. Consent form for the surgery signed by you
6. Financial commitment or means of payment
7. Escort

Mohs surgery – the procedure

Mohs surgery is an ambulatory surgery.

Stage A

You will be under localized anesthesia in the area designated for surgery. After the area is numb, the tumor and another layer of tissue that isn’t visible to the eye will be removed. The spot will be bandaged and you will be moved to the waiting area. While you’re waiting, the surgeon will prepare a Mohs map: imaging of the tissue removed with the surgery wound and preparing a detailed illustration of the wound.

Stage B

The tissue samples are painted and transferred for examination in the lab adjacent to the operating room for a microscopic pathology test.

Stage C

Microscopic testing of the tissue slices. In this thorough test, all the extensions and roots of the tumor, if any, are identified and their location is marked on the Mohs map. If tumor residues are identified beyond the removed tissue, the surgeon uses the Mohs map for precise identification of their location and will return to remove another tissue where tumor roots residue remained.
The surgery will be over when the microscopic test indicates that all tumor tissue has been completely removed.
The surgery’s duration depends on the pathological findings taking place in the lab during it, and in most cases lasts 2-4 hours.

Stage D

There are situations where the surgical wound will heal naturally, without another surgery. However, in quite a few cases, there is need for repair and closing of the surgery wound via continuation procedures. According to the situation, it will be decided if simple suturing would suffice or if the surgical damage requires moving tissue in the surgery area, or transplanting skin from another spot in the body.

Discharge

Prior to discharge, you’ll receive from the surgeon a summarizing letter detailing the course of the surgery and instructions for continued treatment and follow-up in the community.
Remember to schedule a follow-up and stitches removal, in accordance with the instructions you received (usually 7-14 days after the surgery). Several weeks after the surgery, you’ll be invited for a final test and a summary of the surgery results.

The healing process

In most cases, the surgery wound heals within 2-3 weeks after the surgery. The spot of the surgery and the scar undergo a slower recovery process, which could last up to 2 years after the surgery. Avoiding smoking for the first 10 days after the surgery would reduce the risk for damage to the skin flap that seals the surgical wound, and increase the chances for optimal healing of the wound.
In the year and a half after the surgery, it’s important to make sure to use sunblock (SPF>15) and avoiding the exposure of the surgery area and scar to direct sun as much as possible. Remember: The main cause of skin cancer is the sun, and another risk factor is smoking.

Stick to a dermatologist follow up to make sure you get early treatment for any preliminary cancerous lesion!