Mohs Micrographic Surgery

1. Mohs Micrographic Surgery A surgical method I perform in the office to remove skin cancer. Offering: • The highest possible chance of cure • Maximum preservation of normal tissue

2. Mohs Micrographic Surgery • Is named after Dr. Frederick Mohs. • I studied with Dr. Mohs in Madison, Wisconsin to learn this technique. • I was head of the Mohs Unit at OHSU for ten years. • I have done this procedure on thousands skin cancers since 1978.

3. Mohs Micrographic Surgery Many skin cancers have invisible roots that extend into the normal appearing surrounding skin. If your doctor could tell how big the skin cancer was by looking at it, you wouldn’t need Mohs surgery. Mohs surgery is a technique that allows those roots to be followed.

4. Other Treatment Methods • Simple surgical excision (cut it out and stitch it up) • Not so simple excision (plastic surgery) often performed in a hospital with some ability to check margins • Curettage and electrodessiccation (scrape and cauterize) • Radiation therapy • Cryotherapy (freezing with liquid nitrogen)

5. Which Cancer Is Likely To Have “Roots”(and need Mohs Surgery)? • Around the nose, eyes, lips, ears, temple & scalp • Recurrent cancers • Aggressive appearance under the microscope • Blurry margins • Large cancers

6. Mohs Micrographic Surgery Is used for the treatment of: • Basal Cell skin cancer (carcinoma) • Squamous Cell skin cancer (carcinoma) • Malignant Melanoma • Other rare forms of skin cancer

7. Basal Cell Carcinoma • The most common type of skin cancer • It is very slow growing and very rarely ever leads to death • It does not metastasize (spread elsewhere) • If left alone it can, however, eat away a nose, a lip, an ear or you can lose an eye from it. • This would usually require many years

8. Squamous Cell Carcinoma • The second most common type of skin cancer • Responsible for 8-10,000 deaths annually in the United States • In sun exposed areas, usually grows slowly but some grow more quickly • The lip and ear are more dangerous spots

9. Mohs Micrographic Surgery • We do this here in the office usually on a Wednesday or Thursday. • A local anesthetic is used to thoroughly numb the area. • We don’t do surgery unless you are numb!

10. Mohs Micrographic Surgery • Once numb, the soft part of the cancer is scraped away.

11. Mohs Micrographic Surgery A thin layer of tissue (about 2-3mm thick) is then surgically removed from around and under the area. Green, black, blue and red dyes are added so that later, under the microscope, the doctor can tell top from bottom, left from right. A diagram is drawn showing the color codes.

12. Mohs Micrographic Surgery • The area is bandaged. • You are free to wait in the waiting room. • Try a cup of coffee or a pastry next door at the Milky Way Café. • Initial results are usually back within 30-45 minutes

13. Mohs Micrographic Surgery The tissue is: • Frozen • Sliced into thin layers • Placed on glass slides • Stained • The doctor is then called to examine the slides under the microscope.

14. Mohs Micrographic Surgery The doctor then looks at the slides and marks the location of any remaining cancer in red pencil on his diagram.

15. Mohs Micrographic Surgery You return to the surgery room and instead of removing more tissue all the way around and under the wound, I remove more just from the place or places that are still positive. You are bandaged and wait again

16. Mohs Micrographic Surgery • When the slides are ready, I then examine them and once again mark the area or areas where cancer remains. • You come back in and, once again, more tissue is removed just from those areas.

17. Mohs Micrographic Surgery The process can go all day long–––which would be unusual. Or You can finish before lunchtime–––which would be more likely It all depends on the cancer and how far it extends into the normal appearing tissue.

18. Mohs Micrographic Surgery When finished: • I can tell you, as well as anyone can tell you that all the cancer is gone. (This is the method that offers the highest possible chance of cure. Ask the doctor about your chances for recurrence.) • We haven’t removed any more tissue than was necessary to remove the cancer. • There is an ugly hole where the cancer used to be. (That’s what I would call it, if it were on me.)

19. The Wound The final size, shape and depth of the hole is determined by the roots of the cancer.

20. What do we do with the ugly hole? • It can be allowed to heal in by itself or it can be repaired with plastic surgery techniques. • We decide which plastic surgery method to use after we see the final wound.

21. Plastic Surgery Repair • Sometimes, depending on size and location, the wound can be sewed up in a straight line. • Sometimes a skin graft is necessary. (Borrowing skin from elsewhere and sewing in a patch) • A skin flap is sometimes the best way. (Using and rearranging the skin next to the wound, while maintaining its blood supply) • The doctor will discuss options with you.

22. The Risks of Surgery • These are the risks of any minor surgery: • Bleeding • Infection • Scar • The risks related to the specific location of the tumor • The risks related to your specific health problems

23. Blood Thinners to Avoid • For two weeks before surgery, avoid • Aspirin (or anything with aspirin in it) • Vitamin E • Gingko Biloba • Ginseng • Feverfew • For two days before surgery • Ibuprofen (Motrin, Advil) and other arthritis drugs • Ephedra

24. Wound Care • Wound care is different depending on whether you: • Have stitches • Don’t have stitches • You will be given detailed written instructions.

25. If You Have Stitches • The bandage is kept clean and dry until we remove the stitches, 5-7 days for wounds on the face. (This usually means you can’t shampoo in the shower. You can shower from the neck down and possibly do your hair backwards in the sink or at the beauty parlor.) • To decrease any black eye, we often recommend that you go home, sit up in a chair and hold an ice pack on the area on and off (mostly on) until bedtime that night. • No heavy bending or lifting for 2-3 days. • Avoid aerobic exercise for two weeks.

26. No Stitches • Cleanse the wound twice daily. We suggest moistening a cotton-tipped applicator with 0.9% saline solution (Easily found as contact lens solution) and gently rubbing (not rolling) the wound. • Cut out a circle of a non-stick wound dressing. (Telfa™, Release™, or the like) • Cover it with Vaseline™ and apply with paper tape. • It’s OK to get the wound wet in the shower • Exercise is fine

27. Follow-Up • After healing is complete, you need to be checked: • Every three months the first year • Every six months the second year • Yearly until five years have passed

28. Follow-Up • Required mainly for three reasons: • To check for recurrence of the cancer • This is unlikely but still possible. • To work on prevention • Sun protection • Treatment of pre-cancerous spots • To detect any new skin cancer at an earlier stage • Getting a skin cancer gives you a 50% chance of growing another one in the next 3-5 years.

29. Questions • Don’t hesitate to ask about anything you don’t understand. • –Or even something you do understand.