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MOHSMICROGRAPHICSURGERY:PATIENTINFORMATION
DanielleK.Moul,M.D.,F.A.A.D.
DearPatient:
YourdoctorhasreferredyouforMohssurgery,averyeffectivetreatmentavailableforskin
cancer.TheMohssurgerynotonlyprovidesahighcurerate(98-99%)formostprimarytumors,
butalsopermitsoptimalcosmeticresultsbyminimizingtheamountoftissueremoved.
ThispamphletwillfamiliarizeyouwiththeMohsprocedure,andtellyouwhattoexpectwhen
youcomeforsurgery.Itwillalsoteachyouaboutthecausesofskincancer,andhowto
recognizeitandhowtopreventit.Ifyouhaveanyquestionsthatarenotansweredbythis
booklet,pleasefeelfreetocallourofficeatanytime.
Sincerely,
DanielleK.Moul,M.D.,F.A.A.D.
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WhatisSkinCancer?
Canceristissuecomposedofabnormalcellsthatgrowatanuncontrolledandunpredictablerate.Ascancerousormalignanttissuegrows,itinvadesanddestroysthesurroundingnormaltissue.Themostcommontypesofskincancerare:
• Basalcellcarcinoma–commonlyappearsasapearlywhite,pinkorredpatchorbumpthatmaybleedorscabrepeatedly.
• Squamouscellcarcinoma–typicallyafirm,redbumporpatchwithacrustysurface.• Malignantmelanoma–usuallyabrownish-blackpatchorbumpthatenlarges,changesinshape
size,colorand/ormaybleed.Thesecancersoriginateintheskin,but,ifneglected,caninvadeanddestroymuscle,boneandotherstructures.Metastasisisthemigrationofthecancercellbeyondthesiteofitsoriginalgrowthorlesion.Basalcellcarcinomasrarelymetastasize;squamouscellcarcinomascanmetastasizeatarateofabout2-5%especiallyifleftuntreated.Malignantmelanomacanmetastasizeandislifethreateningifnottreatedearly.Unliketheotherformsofcancerininternalbodyorgans,skincancercanbeseenwithouttheaidofsophisticatedmedicalequipment.Thisallowspatientsortheirdermatologisttoidentifytheproblemandseektreatmentearlywhilethecancerisstillsmallandeasilycured.
WhatisaBiopsy?
Abiopsyistheremovaloftissuefromthebodyforpurposesofdiagnosisbymicroscopicexamination.Therearemanybenign(non-malignant)skingrowthsorlesionsthatmaydisplaysomeofthesignsofskincancerlistedabove,butthatareobviouslynotcancerwhenseenunderthemicroscope.Inmanycases,abiopsyistheonlywaytodistinguishbetweenacancerandabenign(non-malignant)moleorwart.Usually,onlyasmallportionofaskingrowthisremoveduponbiopsy,soadditionalsurgeryisrequiredtoremovetheremainderifitprovestobecancerous.
HowisSkinCancerTreated?
Techniquesforthetreatmentofskincancerincludecurettageandelectrodessication(scrapingawaythecanceroustissuewithasurgicalinstrument,andthenusingcauterytostopthebleeding),surgicalexcision(cuttingoutcanceroustissue),cryotherapy(freezingwithliquidnitrogen),topicalcreams(suchas5-Fluorouracilorimiquimodcreamapprovedforsuperficialbasalcellcarcinoma),radiationtherapy,suchaselectronicbrachytherapy(eBx),andMohsmicrographicsurgery.
WhatisMohsMicrographicSurgery?
MohsmicrographicsurgeryisnamedinhonorofDr.FredericMohs,thephysicianwhodevelopedthetechniqueinthe1930s.Thetermschemosurgery,Mohssurgeryandmicroscopicallycontrolledsurgeryallrefertothesametechnique.IntheyearssinceDr.Mohspioneeredtheprocedure,manytechnical
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improvementsandrefinementshavecontributedtomakemicrographicsurgeryasafeandhighlyeffectivemeansoftreatingskinmalignancies.
Themaindifferencebetweenmicrographicsurgeryandothermethodsofremovingskincancerismicroscopiccontrol.InMohssurgery,canceroustissueisremovedinthinhorizontallayers.Eachlayerisdividedintosections,andeachsectioniscarefullyidentifiedand“mapped”bythesurgeonsoitsexactlocationcanbepinpointedonthewound.
Aftercarefulpreparationinthelaboratory,Dr.Moulinspectseachtissuesectionunderthemicroscope.Aslongascancercellsareseenwithinasection,thenDr.Moulcontinuestoremoveandexaminetissuelayersfromthatpartofthewound.BecauseeachlayerisexaminedmicroscopicallytheMohssurgeryprovidesthehighestcurerate.Inaddition,becausenohealthytissueisremovedunnecessarilysuperiorcosmeticresultscanbeachieved.
WhataretheadvantagesofMohsMicrographicSurgery?
• Highcurerate(98%-99%)• Smallestpossiblewound• Optimalcosmeticresult• Convenient:cancerremovedinoneoutpatienttreatmentsession• Cost-effective:fewercancerrecurrences-fewerreturnvisits.• Safe:avoidsrisksofgeneralanesthesia
WhichSkinCancersShouldBeTreatedWithMohsSurgery?
Mohsmicrographicsurgeryisnowuniversallyrecognizedasapreciseandeffectivemethodoftreatingskincancers.Itisespeciallyeffectiveintreatingcancersofthefaceandothercosmeticallysensitiveareasbecauseitcaneliminatecancercellswhilecausingminimaldamagetothesurroundingnormalskin.
Mohsmicrographicsurgeryisalsoidealforrecurrentskincancers,thosethatgrowbackafterprevioustreatment.Whileskincancersareofteneasilyvisible,individualcancercellsaremicroscopic.Root-likeextensionofcancercellsmayreachbeyondthecancer’svisibleborderswithnestsofcellsgrowinginunpredictableareas.Therefore,whatisapparenttothenakedeyeonthesurfaceoftheskinmayactuallybeonthe“tipoftheiceberg”.Anycellsleftbehindcancausethecancertorecur,justasrootsleftbehindwhenpullingweedsmaycauseweedstoregrow.WiththeMohstechnique,tumornestscanbeidentifiedandremovedwithahighdegreeofaccuracy,producingextremelyhighcurerates,ashighas94-98%evenforrecurrentskincancers.YourdermatologisthasreferredyoutoDr.Moulbecausehe/shefeelsthatMohsmicrographicsurgeryisthebesttreatmentforyourskincancer.
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WhoPerformsMohsMicrographicSurgery?
TheAccreditationCouncilforMedicalGraduateEducation(ACGME)hasrecognizedalimitednumberoftrainingprogramsintheUnitedStateswherehighlyqualifiedapplicantsreceivecomprehensivetraininginMohsmicrographicsurgerythroughaProceduralDermatologyfellowship.Thetrainingperiodisusuallyoneyear,duringwhichtimethedermatologistacquiresextensiveexperiencewithallaspectsoftheMohstechnique.Oncethephysician’strainingissuccessfullycompleted,heorshebecomeseligibleformembershipintheAmericanCollegeofMohsMicrographicSurgery(ACMS).
AboutDr.Moul
Dr.Moulisafellowship-trainedMohssurgeonandboardcertifieddermatologist.Dr.MoulcompletedaprestigiousMohsSurgery/ProceduralDermatologyFellowshipatScrippsclinicinLaJolla,California.HerfellowshipisapprovedbyboththeAmericanCollegeofMohsMicrographicSurgery(ACMS)andtheAccreditationCouncilforGraduateMedicalEducation(ACGME).ShetrainedunderDr.HughGreenway,who,hehimselfwastrainedbyDr.FredericMohs.Dr.Moulhashadextensivetraininginfacialreconstructionincludingskinflapsandgrafts.ShehasworkedincollaborationwithPlasticSurgery,Oculoplastics,Otolaryngology,andRadiationOncology.Shehasexperienceinmanagingcomplicatedtumorssuchasrecurrenttumors,tumorspreviouslytreatedwithradiation,andraretumorsincludingmerkelcellcarcinoma,sebaceouscarcinomaanddermatofibrosarcomaprotuberans.
ShehaspublishedabookchapterinInternationalOphthalmologyClinicsonMohsMicrographicSurgeryforPeriorbitalSkinCancer.Inaddition,shewasselectedtopresentresearchontheimportanceofpre-biopsysitephotographattheAmericanSocietyofDermatologicSurgery’snationalmeeting,whichwasalsopublishedas“Whereisit?Theutilityofbiopsy-sitephotography”.SheisamemberoftheAmericanBoardofDermatology,AmericanCollegeofPhlebology,AmericanDermatologicSurgeryandAmericanCollegeofMohsSurgery.Hergoalistoprovideyouwiththebestpossiblecareavailable.Shewelcomesanyquestionsorconcernsyoumayhave.
HowShouldIPrepareforSurgery?
Ifyouaretakingmedication,continuetakingitasprescribedunlesswedirectotherwise.IfyouaretakingCoumadinorwarfarin,Eliquis®Pradaxa®,orXarelto®pleasenotifytheoffice.Ifyouhavenothadaheartattack,stentorstroke,etc.,andaretakingitforpreventiononlypleasediscontinueaspirinandmedicationsthatcontainaspiring(Anacin®,Bufferin®,Excedrin®,Alka-Seltzer®,etc.)foratleasttendays(10)dayspriortoand5daysfollowingsurgery.Alsoavoidanti-inflammatorymedications(Advil®,Aleve®,diclofenac,Ibuprofen,Nuprin®,indomethacin,Naprosyn®,etc.forthesametimeperiod.Thesemedicationstendtoincreaseandprolongbleedingduringsurgeryandmayinterferewithwoundhealing.YoumaytakeTylenol®(acetaminophen).Alcoholicbeveragesshouldbeavoidedfor72hourspriortoand72hoursfollowingsurgeryasalcoholdilatesbloodvesselsandcanpromotebleeding.PleasediscontinueCoQ10,vitaminE,fishoilandSt.John’swortfor10dayspriortosurgeryand5daysfollowingthesurgery;thesevitaminscanincreaseyourriskofbleeding.
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Ifyouhaveaheartmurmur,anartificialheartvalveoranyartificialjointsorimplantswiththepast2years(otherthanpacemaker),youwillneedtotakeanantibioticthedayofsurgerytopreventinfection.
Pleasenotifyussothatthismaybeprescribedinadvance.Getagoodnight’srest,eatbreakfastandcometotheofficeatyourscheduledtime.
TheDayofSurgery
Surgeryusuallybeginsearlyinthemorningsothatthesurgicalstagescanbecontinuedthroughouttheday,ifnecessary.Youshouldplantospendtheentiredaywithus.Pleasedon’tmakeothercommitmentsfortheday.Surgeryisnearlyalwaysfinishedthesameday,unlessthetumorisextensiveoramoreinvolvedrepairisrequired.WhilethelengthoftimerequiredforMohssurgeryisinitiallysurprisingandperplexingtosomepatients,thefollowingdescriptionoftheprocessgenerallyalleviatessuchconcerns.
First,alocalanestheticisusedtonumbtheskinaroundthetumortopreventdiscomfortduringsurgery.Ifyousufferfromanxietyornervousabouttheprocedure,pleaseletyourdoctorknowsotheymayprescribemedicationifneeded.Whentheskinisnumb,Dr.Moulthenremovesalayeroftissueinvolvedbythecancer,bleedingisstoppedwithelectrocoagulation,andadressingisapplied.Theproceduretothispointtypicallyrequires10-15minutesforeachtimetumorisremoved.
Theremovedtissueissenttothelaboratorywhereitispreparedformicroscopicexamination.Laboratorypreparationandexaminationunderthemicroscopearedelicateproceduresandrequiregreatprecision.Theyarealsotime-consumingapproximatelyanhourisrequiredeachtimetissueisexcised.
Themostdifficultpartoftheprocedureforyouwillbewaitingfortheresultsofthemicroscopeexamination.Youwillwanttowearcomfortableclothing,considerbringingasnackorlunch,aswellasreadingmaterial,IPAD,computer,paperwork,crosswordpuzzlesorotheractivitiestohelppassthetime.
Ifforsomereason,youmustleavetheoffice,itisveryimportantthatyoufirstcheckwithanurseandleaveanumberwhereyoucanbereached.Pleasebringafriendorarelativetodriveyouhomeafterthesurgeryifyouarehavingsurgerynearyoureye,areanxiousabouttheprocedureandreceivingasedativeorrequireextraassistance.
Oncetheskincanceriscompletelyremoved,Dr.Moulwilldiscusswithyoutheoptionsformanagementofthesurgicalwound,usuallytherearetwochoices:letthewoundhealbyitselfwhichusuallytakes4to12weeksorclosethewoundwithstitches.Dependingonyourwounditmaybeclosedsidebyside,byaskipflap(tissuemovedfromnearbyskin)oraskingraft(tissueremovedfromanothersiteandtransferredtothewound).Aside-to-sideclosureisthemostcommonclosureandisknownasacomplexlinearclosure.Complexlinearclosuresaretypically3timesthelengthasthewidthofthewound.Youwillnoticeyourincisionis3timeslongerthanthesizeofthedefect.Thisissothescarwillhealintoafinethinlinewithouttheendsbeingraised.Dr.Moulwillrecommendwhichofthesechoiceswillbebestinyourcase.Ifitisdeterminedthatthewoundshouldberepaired,thisisusuallyperformedbyDr.Moulthesameday.
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ThePost-OperativeCourse
Sinceyouwillprobablybefatiguedyoushouldplanontakingiteasyandgettingplentyofrestthefirstnight.Mostpatientsdonotcomplainofpain.TwoTylenol(1,000mgacetaminophen)takenevery6hoursareusuallysufficienttorelievethediscomfortsomepatientsexperiencethefirst12to24hours.Swellingandbruisingareverycommon,particularlywhensurgeryisperformedonthenoseoraroundtheeyes,andgenerallyresolvewithinaweekto10days.Painlessred,purpleoryellowbruisingandswellingoftheeyelidsoftenappear2-3daysaftersurgeryontheforehead,frontportionofthescalp,noseortemplesandarenocauseforconcern.Theuseofextrapillowsthefirst4nightsfollowingsurgerytokeeptheheadandshoulderselevatedwhilesleepingandicepackswrappedintowelsastoleratedfor10minutesatatimehelpminimizethis.
Veryoccasionallythereiscontinuedbleedingfollowingthesurgery.Ifthisoccurs,liedownandremoveallthebandages,andwithgauze,applyfirm,steadypressurefor20minutes(timed)overtheareaofthewoundthatisoozingblood.Donotliftthegauzetocheckonthebleedingbefore20minuteshavepassed.Ifthebleedingpersistsafter20minutesofsteadypressure,immediatelynotifyouroffice,orgotothenearesthospitaloremergencyroom.
Allwoundsnormallydevelopasmallhaloofrednessaroundthem,whichgraduallydisappears.Ifincreasingredness,warmth,tendernessorpaindevelop,thewoundismalodorous,orthereispusdrainingfromthewound,callourofficeimmediately.Thewoundmayhavebecomeinfectedandanantibioticmaybenecessary.Iftheskinaroundthewoundbecomesveryitchyandred,youareprobablyhavingareactiontotheadhesivetapeortheantibioticointmentusedtodressthewound.Youshouldcallourofficeifthisoccurs.
AftertheWoundHasHealed
Somepatientsmayexperiencesensationsoftightness,numbness,tingling,sensitivitytothetemperaturechange,oritchingaroundthesurgicalsite.Thesesensationsarenormalandtendtoimprovewithtimeoverseveralmonths.Gentlymassagingthesiteseveraltimeseachdaycanspeeduptheprocess,however,thisshouldnotbedoneuntilatleast3weeksaftersurgeryasadvisedbyDr.Moul.ItchingmaybeduetodrynessandcanbeimprovedwithplainVaseline.Rednessatthesiteisalsonormalandwillgraduallyfade,usuallyby6months.
Afollow-upperiodofregularskinchecksatintervalsofevery6monthstoyearlyisessential.50%ofpatientswilldevelopanotherskincancerintheirlifetime.Therefore,patientsreturntotheirdermatologist,forexaminationtodetectanyneworrecurrentskincancersandtreatthemintheirearlystages.Besuretoreportimmediatelytoyourdermatologistanysuspiciouslesionsyouhavenoticedonyourskintoseeifabiopsyisnecessary.
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CommonlyAskedQuestions:
1. WilltheSurgeryLeaveaScar?
Yes.Anysurgicaltreatmentwillleaveascar.However,theMohstechniquetendstominimizethisasmuchaspossibleandDr.Moulisspeciallytrainedinthereconstructiontominimizescarring.
2. ShouldPlasticSurgeryBePerformed?
Dr.Moulisafellowship-trainedMohssurgeonwhohascompletedaprestigiousfellowshipatScrippsclinicinLaJolla,California.HertrainingincludedcarefulevaluationsofMohsdefectsandfacialreconstructionincludingflapsandgrafts.Shehasworkeddirectlywithplasticsurgery,oculoplasticsurgeryandENTandhasbeentrainedtohelpprovideyouwithoptimalcosmeticresults.Theoverallcosmeticappearancewillcontinuetoimproveforatleastayearaftersurgery.Inrareinstancesyourrepairmaybecoordinatedwithaplasticsurgeonifthesurgicalwoundrequiressedationorisalargedefectrequiringarepairinanoperatingroom.
3. MohsMicrographicSurgeryPreoperativeChecklist
• 10dayspriortosurgery1. IfyouhaveNOThadaheartattack,stent,bloodclotorstrokeandtakingitpurelyfor
preventionstopaspirinandaspirin-containingmedications(includingExcedrin®,Bufferin®,Alka-seltzer®,Ecotrin®,etc.)
2. StoptakingCoQ-10,VitaminE,FishOil,orSt.John’swortsupplements3. IfyouareonCoumadinorwarfarin,pleasenotifytheofficeofyourrecentlabwork,INR.
4. IfyouaretakingEliquis®,Pradaxa®orXarelto®,pleasenotifytheoffice.5. Stopanti-inflammatorypainmedications(includingAdvil®,Aleve®,Ibuprofen,
Naprosyn®,andDaypro®etc.• Continueallotherprescriptionmedications.• Cancelothercommitmentsforthedayofsurgery–you’llwanttotakeiteasyforatleast24
hours.• 72Hoursbeforeandaftersurgery:discontinuealcoholicbeverages• Arrangeforaridehomeafterthesurgeryifneeded• Fillanypreviouslyorderedprescriptionsforpre-operativeantibioticsand/orsedatives• Eatbreakfastandtakeyourusualmedications(exceptthoselistedabove)thedayofsurgery• Itisagoodideatobringasnackorlunch.• Bringreadingmaterial,paperwork,IPAD,laptop,Kindle,etc.
