About Skin Cancers and Mohs Micrographic Surgery
Skin Cancers
- Basal Cell Carcinoma
- Squamous Cell Carcinoma
- Melanoma
Basal cell carcinoma is the most common type of skin cancer. It usually appears as a sore that won’t heal or a pearly, shiny bump or knot that sometimes has small blood vessels within the affected area. The area may bleed with minor trauma. There are several other presentations including one that appears like a red, rough patch. Sometimes, they are mistaken for pimples, cysts and rashes. Basal cell carcinoma does not progress to invade the blood stream except under extreme circumstances. However, it can invade and destroy the local area and cause deformity if left unchecked.
Squamous cell skin cancer is the second most common type of skin cancer. It arises from the outer layer of the skin. Squamous cell carcinoma can occur anywhere on the skin but is most common on the face and arms. It often appears as an opaque or scaling patch or bump in sun-exposed areas, and may be mistaken for a wart or patch of dry skin. Unlike basal cell carcinoma, squamous cell carcinoma can progress far enough to get into the lymph nodes and blood stream and become a threat to a patient’s life. This is more common in large, aggressive squamous cell carcinomas or in cancers on the ears, upper head, lips or genitalia, or skin cancers that have been treated before, but have now come back. The overall chance of any squamous cell carcinoma spreading outside the local region is about 2%, but this can be much higher depending on the location of the cancerous site or other features.
Melanoma is the most deadly skin cancer, but has an excellent prognosis if it is caught early. Though melanoma may occur anywhere on your skin, melanoma is found most often on the legs of women or the backs of men. It is usually a brown to black lesion which is not uniform in border, color or surface. The “ABCDE’s of melanoma” have been described to help distinguish a regular mole from melanoma. The acronym stands for Asymmetry (most healthy moles are uniform), Border (irregular), Color (irregular or change in), Diameter (larger than a pencil eraser-not reliable), and Evolving (changing). Melanomas on chronically sun-damaged skin like the face may appear like a brown patch or freckle with irregular color. Melanomas may be treated with Mohs Micrographic Surgery.
Mohs Micrographic Surgery
- History
- What is Mohs Micrographic Surgery?
- Effeciveness of Mohs Surgery
- Mohs Surgery Process
- Mohs Surgery Reconstruction
- a small, simple wound may be allowed to heal on its own.
- a slightly larger wound may be closed with stitches.
- larger wounds may require a skin graft or a flap.
- if the tumor is very large, another surgeon with special skills may be called upon to assist with reconstruction.
- Will I be Hospitalized?
- Will I have a Scar?
- Mohs Post-Surgery Management
- The Mohs Surgeon
The term “Mohs” refers to Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, who developed this surgical technique in the early 1940s. The technique has undergone many refinements and has come to be known as “Mohs surgery” in honor of Dr. Mohs. Dr. Mohs recognized that a skin cancer often resembles a “tip of the iceberg” with more tumor cells growing downward and outward into the skin, like the roots of a tree. These “roots” are not visible with the naked eye, but can be seen under a microscope.
Mohs Micrographic Surgery is a highly specialized and precise treatment for skin cancer in which the cancer is removed in stages, one tissue layer at a time. It is an outpatient procedure. The removal technique is no different than other procedures; however it is distinguished by a specific technique of tissue examination that is unique to Mohs surgery. Although some plastic surgeons and other specialists check excision margins, pathologic examination of the tissue is not the same as Mohs surgery. Once a tissue layer is removed, the edges are marked with specially colored dyes, and a map of the specimen is created. The tissue is then processed onto microscope slides by a Mohs histotechnician. These slides are carefully examined under the microscope by the Mohs surgeon so that any microscopic roots of the cancer can be precisely identified and mapped. When cancer cells are seen, an additional tissue layer is removed only in areas where the cancer is still present, leaving normal skin intact. This saves as much normal, healthy skin as possible. Once the cancer has been removed, the Mohs surgeon will explain options for repair of the wound, including natural healing (granulation), stitching the wound together by a side to side closure, or using a skin flap or graft.
Mohs surgery has the highest success rate of all treatments for skin cancer – up to 99 percent. It is the best treatment for cancers of the face and other sensitive areas because it relies on the accuracy of a microscopic surgical procedure to trace the edges of the cancer and ensure complete removal of all tumors down to the roots during the initial surgery.
Mohs surgery is usually an outpatient procedure performed in a physician’s office. Typically, it starts early in the morning and can be completed the same day, depending on the extent of the tumor and the amount or reconstruction necessary. Local anesthesia is administered around the area of the tumor so the patient is awake during the entire procedure. There are six steps to the process: 1. The roots of a skin cancer may extend beyond the visible portion of the tumor. If these roots are not removed, the cancer will recur. 2. The visible portion of the tumor is surgically removed. 3. A layer of skin is removed and divided into sections. The ACMS surgeon then color codes each of these sections with dyes and makes reference marks on the skin to show the source of these sections. A map of the surgical site is then drawn. 4. The undersurface and edges of each section are microscopically examined for evidence of remaining cancer. 5. If cancer cells are found under the microscope, the ACMS surgeon marks their location onto the ‘map’ and returns to the patient to remove another layer of skin – but only from precisely where the cancer cells remain. 6. The removal process stops when there is no longer any evidence of cancer remaining in the surgical site. Because Mohs surgery removes only tissue containing cancer, it ensures that the maximum amount of healthy tissue is kept intact.
The ACMS surgeon is also trained in reconstructive procedures and often will perform the necessary reconstruction to repair the wound. As soon as the affected area is declared cancer-free, the Mohs surgeon discusses post-surgical options with the patient such as:
No. Mohs surgery is performed in an outpatient surgical suite and you may return home the same day.
Yes. All skin cancer surgical treatments will leave a scar. However, because Mohs surgery removes as little normal tissue as possible, scarring can be minimized. After the cancer is removed Dr. Lim Quan will discuss the options to: 1) Leave the wound to heal by itself; 2) Repair the wound with stitches; 3) Shift healthy skin from nearby to cover the wound (flap) or 4) Cover with a skin graft. This decision is based on the safest method that will provide the best cosmetic result.
Post-surgical check-ups are recommended in order to monitor the patient’s progress and spot any possible cancer recurrence in a timely manner. Since two of five patients with one skin cancer will develop another within five years, follow up is extremely important for early detection of any new lesions.
Mohs surgeons who are members of the American College of Mohs Surgery have undergone at least one year of fellowship training beyond dermatology residency, which allows for additional experience in all these specialized processes and techniques. Dr. Lim Quan is a fellow of the American College of Mohs Surgery.
Play the short video below to learn more about the Mohs procedure. © American College of Mohs Surgery