What is Mohs Surgery?

Mohs Surgery is a specialized procedure that treats skin cancers by removing the cancer layer by layer. It is named in honor of Frederick Mohs, a surgeon who pioneered the procedure in the 1930's, The purpose of Mohs surgery is to remove the least amount of tissue with the highest possible cure rate. Mohs Surgery is performed as outpatient procedure at our office under local anesthesia.

Many skin cancers are often described as having "roots" that extend beyond the apparent borders of the tumor. By using the Mohs Surgery technique, the borders or margins of the tumor are checked to remove these "roots". This allows for a higher cure rate than other techniques. Mohs Surgery has a cure rate that approaches 99% for primary (never treated) basal cell carcinomas. For recurrent tumors, the cure rate of Mohs Surgery is 95% (compared to 80% with other modalities).

Use the links below to learn more about Mohs Surgery at Vanguard Dermatology.

Is Mohs Surgery right for me?

If this is your first time having Mohs surgery, Dr. Shapiro would like to meet with you prior to having the procedure done. This will allow him to examine your skin cancer, obtain a medical history, and determine whether the technique of Mohs Surgery would be the best treatment for your skin cancer. It will also allow you to learn about the procedure and ask any questions that you may have.

How is Mohs Surgery performed?

First, the area around the tumor is numbed using local anesthesia to eliminate pain. This usually stings for a few seconds and is usually the only pain felt throughout the whole procedure.

Then, the visible portion of the tumor is carefully removed using a scalpel or curette.

The next step involves removal of a layer of tissue to check the margins for presence of tumor. A 1-3mm margin around the tumor is drawn and a thin pancake-shaped piece of tissue is removed using a sharp scalpel.

We then bring this tissue to the laboratory, process the tissue, and prepare slides. This slide-making process may take 60 to 90 minutes. During this time, a bandage is placed on your wound and you may be brought to the waiting room area to await the results.

When the slides are ready, Dr. Shapiro then examines both the lateral and deep margins of the tissue with a microscope and checks for tumor. The results of this step are recorded on a map of the treatment area.

If there is any tumor left in any section, you are brought back to the surgery room, and another tissue layer is taken, to again check the margins for tumor. This process is repeated until the base and sides of the tumor no longer contain tumor cells.

Reconstructive Surgery

Once the tumor is removed, you are left with a surgical wound. Dr. Shapiro will discuss the repair options with you and make recommendations on the option that will achieve the best cosmetic and functional result. These options may include:

1) Natural Healing
In certain areas of the face and body, wounds heal better when left to heal naturally. Wounds healing on their own may take a month or more to fill in and you may need to change the bandages regularly during this time.

2) Closing with stitches
This involves pulling the wound edges together and closing the wound with surgical stitches. The suturing usually lasts anywhere from thirty minutes to two hours to complete. You will need to return to have the stitches removed, which is usually one week later on the face and two weeks later on other parts of the body.

3) Skin Graft
This option involves taking skin from another part of the body and stitching it into place to close the wound. A bolster dressing is sewn over the graft and remains in place for at least a week. You should not get the dressing or the underlying graft wet during this time. It may be recommended that you bathe using a sponge bath during this week. The stitches on the bolster dressing are usually removed in 1 week. The stitches on the graft are absorbed by the body and do not need to be removed.

4) Skin Flap
This process involves surgically cutting and pulling skin from an area adjacent to the wound and stitching it in place. Usually you will need to return in 1 week to have the stitches taken out. Sometimes skin flaps may require a second stage or additional surgery to complete. This may be scheduled 2-3 weeks after the initial surgery.

5) Consultation with another surgical specialist
Dr. Shapiro may recommend that you see another surgical specialist to discuss repairing the surgical wound after Mohs Surgery. They will often require that you meet with them in consultation prior to surgery. Our office will make arrangements with the other surgical specialist’s offices to arrange your surgery dates. You may be having surgery with the specialist on the same day or several days after your Mohs surgery procedure. Infrequently, the surgical specialist will require that you do not eat on the day of the surgery (if your repair will be done in a hospital operating room and require general anesthesia).

How to Prepare for Mohs Surgery

In general, you should treat your day of having Mohs Surgery similar to any other day. Be sure to take all your regularly scheduled physician-prescribed medications. If you are on blood thinners, Dr. Shapiro can discuss with you the risks and benefits of taking these medications.

The main thing to prepare for with Mohs surgery is a long full day, most of which is spent waiting for slide results. As such, you should bring food to eat and possibly something to read and/or someone to keep you company.

What to Expect on the Day of Mohs Surgery

Our nurses will bring you to our surgical suite. Together, we will identify and confirm with you the location(s) of the tumor(s). We will then anesthetize the area with local anesthesia. We then perform the first stage of Mohs surgery which usually takes 20-30 minutes. You will then be bandaged and taken to the waiting room. It takes approximately 1-1.5 hours for the tissue to be processed and stained. After this we will repeat the Mohs surgery stages and tissue processing as necessary to clear the tumor. It usually takes most patients 2-3 stages to clear a tumor, with each stage taking approximately 1-1.5 hours. Occasionally, it can take 4-5 or more stages to clear the tumor. Sometimes, but rarely, we are not able to completely clear the tumor in one day and may ask you to come back the following day to continue the Mohs surgery procedure. After the Mohs surgery procedure is complete, we will discuss the reconstructive options with you. The reconstructive procedure may take an additional 1-3 hours to complete.

Once the surgery is complete, our nurses will give you written and verbal instructions on how to care for your wound. If prescriptions for antibiotics or pain medications are indicated, you will receive them at this time.

There may be other patients who are getting Mohs surgery the same day as you and some patients may be finished earlier or later than you. Every patient is unique and some patient’s procedures and slides may take a longer or shorter time to process.

After Mohs Surgery

Healing and wound care will be explained in depth to you following Mohs surgery. In general, wounds tend to heal better when covered with ointment and a bandage. We usually recommend the use of plain Vaseline or Aquaphor as a covering ointment to be applied 1-2 times per day.

It is common to experience mild pain for several days following the Mohs surgery procedure. Usually over-the-counter extra strength Tylenol (acetaminophen) taken at recommended doses is enough to relieve the pain. If you are still having pain, please contact Dr. Shapiro on his cellular phone so he can evaluate your symptoms.

It is also common to feel fatigue for one to two days following Mohs surgery and most people elect to rest and not work during this time.

Look for signs of infection including tenderness, warmth, fever, and pus at the wound site. If you notice these or other signs, please contact our office immediately.

It is important to make an appointment and see your referring dermatologist or physician for a complete skin check 3-6 months after completion of the Mohs surgery, or earlier. Regular skin surveillance is critical for early detection and prevention of skin cancer.

Vanguard Dermatology is a comprehensive dermatology practice with offices in SoHo, Sheepshead Bay, Greenpoint, Forest Hills and Staten Island, dedicated to treating skin conditions for patients of all ages.