Skin Cancer is by far the most common malignant tumor. More than 1.2 million Americans are diagnosed with skin cancer each year. The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. 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 or “ roots” of the tumor cannot be directly seen. The tumor roots often extend far beyond what is visible on the surface of the skin. So what is seen by the naked eye is the “ tip of the iceberg” and much of the tumor may be under the skin. If not completely removed, skin cancer will continue to grow and invade and destroy structures in their path. Metastasis (distant spread) of basal cell carcinoma is extremely rare and usually occurs only in the setting of long-standing large tumors where the patient’s immune system is compromised. Squamous cell carcinoma is more dangerous, and patients must be observed for any spread of the tumor, although this is still infrequent.
Excessive exposure to sunlight (beginning in childhood) is the single most important factor associated with the development of skin cancers. In addition, the tendency to develop these cancers appears to be 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 radiation, trauma, and exposure to certain chemicals, may also be involved in the development of skin cancers. Skin cancers may be more aggressive in certain instances: patients whose immune system is compromised, patients with a medical history of leukemia or lymphoma, cancers in certain locations such as the ear, lips, lower nose or around the eyes.
Mohs Micrographic Surgery
Mohs micrographic surgery is a state-of-the-art treatment for skin cancers where the Mohs surgeon acts as surgeon, pathologist and reconstructive surgeon. It is named after the surgeon, Dr. Frederick Mohs, who pioneered this precise technique. Mohs surgery relies on the precision and accuracy of a microscope to identify and map out the roots of the skin cancer to give the highest chance that the entire tumor will be removed (exceeding 97%). There are other methods to treat skin cancer like cryosurgery (freezing), electrosurgery (burning), standard surgery, radiation and laser. But these methods do not have as high a cure rate as Mohs surgery. No surgeon or technique, however, can guarantee 100% cure. Mohs micrographic surgery allows for the selective removal of the skin cancer with the preservation of as much of the surrounding normal tissue as possible.
As a result, Mohs micrographic surgery is very useful for tumors that are:
- with more infiltrative growth
- with indistinct borders
- on or near important structures like the eyelid, nose, mouth, lips and ears
Once the obvious surface tumor is removed, there are two basic steps to each Mohs micrographic surgery stage. First, a thin 1-2 mm layer of tissue is surgically and precisely excised around and below the area. This layer of tissue is mapped out and oriented so that the exact location of the tumor is known in relation to the area of the surgical site.
Next, this layer of tissue is processed in a unique manner by our histotechnician and examined under the microscope by the Mohs surgeon. This differs from the “ frozen sections” prepared in a hospital setting which represent only a tiny sampling of the tumor margins. If any tumor roots are seen during the microscopic examination, the exact location is determined via the precise map and a thin layer of additional tissue is excised only at the precise location of the tumor root. The entire process is repeated until no tumor is found. Thus, Mohs micrographic surgery maximizes the chances that all the tumor is removed and minimizes the removal of normal tissue.
Michael J. O’Donnell, M.D., graduated from Thomas Jefferson Medical School in Philadelphia. Following five years in the United States Navy serving as a Naval Flight Surgeon, he completed a three-year Dermatology residency at the University of Iowa Hospitals and Clinics where he served as chief resident. Dr. O’Donnell is Board Certified in Dermatology. He then completed an additional two-year Fellowship training in Dermatologic Surgery and Oncology and Mohs Micrographic Surgery at the University of Iowa Hospitals and Clinics and is a Fellow of the American College of Mohs Micrographic Surgery and Cutaneous Oncology and the American Academy of Dermatology.
Mark F. Suchter, M.D., graduated from Drexel University College of Medicine in Philadelphia, Pennsylvania. He completed his residency in Dermatology at the University of Medicine and Dentistry of New Jersey where he served as chief resident. After residency, Dr. Suchter completed his fellowship in Mohs Micrographic Surgery at Geisinger Medical Center and is Board Certified in Dermatology. He is a member of many organizations including the American Academy of Dermatology, the American College of Mohs surgery and the Pennsylvania Academy of Dermatology.
Jean Kilcullen, R.N., is a Mohs surgery nurse. Jean received her Associates Degree in Nursing at Marymount College of Virginia. She also received her Bachelor of Arts Degree in Psychology and her Elementary Education Certification from Rosemont College. She is a member of the Dermatology Nurses’ Association.
Gina Ackley, H.T.(ASCP), is a Mohs laboratory histotechnician. Gina received her histology training at the Geisinger Medical Center and is a member of the American Society of Mohs Histotechnology. Gina is board registered with the American Society of Clinical Pathologists.
Dawn Henehan, R.M.A., is a Mohs laboratory histotechnician and Mohs Medical Assistant. Dawn received her certification at Ultrasound Diagnostic Schools in Iselin, New Jersey, and is registered with the American Medical Technologists. She is also a member of the American Society of Mohs Histotechnology.
Anne Kish, C.C.M.A., is a Mohs nursing assistant. Anne received her diplomas as a Nursing Assistant and Medical Assistant from the Stratford Career Institute. She received her certification from the National Healthcareer Association.
Molly McNally, L.P.N., is a Mohs surgery nurse. Molly received her certification from Career Technology Center of Lackawanna County Licensed Practical Nursing Program. She is a member of the Dermatologic Nurses’ Association.
Andrea Leshock, C.M.A., is a Mohs Medical Assistant. Andrea received her associates degree from McCann School of Business and Technology. She received her certification from the American Association of Medical Assistants.
Sarah Stanton, C.C.M.A., is a Mohs Medical Assistant and is a certified dermatology technician through the Association of Certified Dermatology Technicians. She received her certification from the National Healthcareer Association.
Nicole Spak is a Mohs laboratory histotechnician and Mohs Medical Assistant. Nicole received her associates degree from McCann School of Business and Technology. She is a member of the American Society of Mohs Histotechnology.
Holly Green, C.C.M.A., is a Mohs Medical Assistant. Holly received her associates degree from McCann School of Business and Technology.
Melissa Keiser, C.C.M.A., is a Mohs Medical Assistant and is a certified dermatology technician through the Association of Certified Dermatology Technicians. She received her certification from the National Healthcareer Association.
Georgann Wywoda, B.S.R.T(R)(MR), is a Mohs Medical Assistant. Georgann received her Bachelor of Science Degree in Radiography from Misericordia University.
What you should know…
In some circumstances, Dr. O’Donnell or Dr. Suchter will want to meet you prior to the surgery day for a
preoperative evaluation. Also, if you would feel more comfortable meeting them before the surgery to discuss any questions or concerns, we will schedule a consultation. Our Mohs surgery staff will contact you as soon as possible concerning the date of your surgery. If you take Coumadin, Aspirin, Pradaxa, Eliquis, Xarelto, Aggrenox or any other blood thinners prescribed by your doctor or if you routinely take antibiotics prior to surgery, please inform our Mohs surgery staff for discussion of any further instructions. Your doctor may have to be contacted.
Before Mohs Micrographic Surgery
If you take any aspirin or other blood thinners, please notify us and we will give you further instructions. If you were instructed to discontinue prescribed blood thinners prior to surgery, in most cases, they may be restarted later that evening after the surgery. If you do drink alcohol, please limit to one drink/day one day prior to your surgery and two days after your surgery. Stop smoking (or reduce as much as possible) two weeks before and two weeks after surgery since smoking increases the chance for poor healing and scarring especially if a skin graft or flap is utilized to repair the area.
Beginning several days prior to surgery, use antibiotic soap like Lever 2000, Dial, or Cetaphil Antibacterial Bar on the area and surrounding areas of the skin cancer. Shampoo your hair the night before the surgery, as your wound and initial dressing may need to remain dry for 48 hours.
The length of the procedure varies depending on the size and location of the tumor, the number of layers required as well as the type of reconstruction or repair needed. Please be prepared to be with us for at least 3 – 4 hours and possibly longer.
Much of the time spent is waiting for the tissue to be specially processed so that it can be examined under the microscope so please bring along a book or handiwork to keep busy. In some cases, we ask that someone accompanies you or drops you off and picks you up because you may be tired after the day and may have a bandage or pre-op medicines which will prevent you from driving safely. We ask that you limit the number of people accompanying you to one or two because of the limited space in our surgical waiting room.
Try to get a good night sleep and eat a good breakfast (even if you normally do not eat breakfast) unless you were told otherwise or if you are being repaired by another surgical specialist. Take all your medicines as you normally would and bring your medicines if you take them in the afternoon unless you were instructed otherwise. Please be on time for your appointment and allow enough time for parking and morning work traffic. You will be scheduled with other patients and failure to be on time will affect all of our patients and office as well. It is a good idea to wear loose fitting clothing and avoid pullover clothing. Although snacks are provided, pack some of your favorite snacks which do not require refrigeration or heating in case you get hungry. If the surgery site is on the face, please do not wear make-up. 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 antibacterial solution. The area will then be anesthetized (numbed) with a small local injection. This injection is very similar to the one you received for your skin biopsy; however, we buffer our solution with sodium bicarb so it is not as painful. We will be as gentle as we can when administering this injection. It usually takes 30 minutes to anesthetize the area and remove the tissue. After the tissue has been removed, it will be processed in our laboratory. Most skin cancers are removed in 1 – 3 surgical stages.
After the skin cancer has been completely removed, a decision is made about the best method for closing the wound. These methods include letting the wound heal by itself, closing the wound side-to-side, delaying the closure for a future day or closing the wound with a skin graft or flap. We individualize your treatment to achieve the best results. When the reconstruction is completed by other surgical specialties, that reconstruction usually takes place on the same day or next day. There is no harm in delaying the reconstruction.
AFTER MOHS MICROGRAPHIC SURGERY
Your surgical wound will likely require care during the week following surgery. Detailed oral and written instructions will be provided. You should plan on avoiding strenuous activity for a week after the surgery. If the surgery is located on your extremities or back you may have to avoid strenuous activity longer than a week. It is prudent to plan to stay in the area during the week after the surgery to ensure proper evaluation if any problems result. Most of our patients report minimal pain which responds readily to Tylenol, however a pain medication may be prescribed in certain cases.
An ice pack over the bandage may also help with pain and swelling. Bruising (“black and blue”) and swelling may develop especially around the eyes, cheeks and neck and will resolve during the healing phase. You may experience a sensation of numbness, tightness, and “pins and needles” across the area of surgery afterwards. Skin cancers frequently involve the superficial skin 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, however you will see improvement as each week and month passes. Especially during the first few months, the scar site may feel “ thick, swollen, or lumpy” and there may be some redness. This redness is due to increased size and number of blood vessels in the area of surgery.
The redness usually fades after several months; however, rarely these blood vessels can be permanent. Gentle massage of the area (starting about 1 month after the surgery) will speed the healing process. Studies have shown that once you develop a skin cancer, there is a 50% chance of developing other skin cancers in the future. Should you notice any suspicious areas, it is best to check with your physician for an examination. You will be reminded to return to your dermatologist or family doctor on a frequent basis for continued surveillance of your skin once the surgery is completed.
As with any type of surgery there are possible complications and risks which may occur. Because each patient is unique, it is impossible to discuss all the potential complications and risks in this format. The usual risks are discussed below. Dr. O’Donnell or Dr. Suchter will discuss any additional risks associated with your particular case. Please understand that these occurrences are the exception and not the rule.
- The defect or wound created by the removal of the skin cancer and it’s underlying roots will be larger than anticipated. This is due to the fact that a skin cancer seen on the surface is sometimes the “tip of the iceberg” and frequently more of the tumor is underneath the surface where only the microscope can see. There is no way to predict the final size of the wound prior to surgery.
- There will be a scar at the site of the removal. There is no such thing as scarless surgery. We will make our best efforts to obtain optimal cosmetic results. Again, Mohs surgery will leave you with the smallest possible wound, thus creating the best opportunity for optimal cosmetic results. Rarely, an additional revision surgery is needed after Mohs surgery to optimize the cosmetic or functional outcome.
- 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 re-open. Flaps and grafts used to repair the defect may sometimes fail. Under these circumstances, the wound will usually be left to heal on its own and you will need close follow-up care.
- There may be a loss of motor (muscle) or sensory (feeling) nerve function. Rarely, the tumor invades or wraps around nerve fibers. When this is the case, the nerves must be removed along with the tumor. Prior to surgery, Dr. O’ Donnell or Dr. Suchter 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.
- Wounds rarely become infected (fewer than 1%), requiring antibiotic treatment. The typical signs of infection are increasing pain, swelling and drainage. 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 will be controlled during surgery. There may also be bleeding after surgery. If you experience bleeding after surgery, apply firm pressure over the wound with a clean dry cloth or towel for 30 minutes. You will be given detailed written instructions concerning any bleeding after the surgery.
- Significant blood loss is very rare, but bleeding into a sutured graft or flap may inhibit good wound healing and thus increase the chance for the graft or flap to fail or not “take”.
- 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 recur after surgery. Previously treated tumors and large, longstanding tumors have an increased chance for recurrence.
- DO advise us as soon as possible if you must cancel or change your appointment. We do have a waiting list of skin cancer patients. The sooner you notify us of a change in your scheduled appointment the more time we have to schedule someone in your place.
- DO get a good night’s sleep prior to surgery.
- DO stop smoking or decrease as much as possible two weeks before and after surgery.
- DO eat a good breakfast.
- DO take all your usual medications on schedule unless otherwise instructed.
- DO arrive on time for your appointment allowing time for A.M. traffic and parking.
- DO dress comfortably. Since bleeding is an inherent risk of any surgical procedure, consider dressing in clothing which would not pose a problem to you if soiled.
- DO ask any questions you might have.
- DO let us know if you take Coumadin, other blood thinners, aspirin or antibiotics prior to surgery.
- DO limit alcohol to one drink/day one day prior to your surgery and two days after your surgery if you do drink alcohol.
- DO NOT take aspirin or any other aspirin products two weeks prior to surgery unless otherwise directed.