Mohs Surgery

Mohs micrographic surgery is the most effective and advanced treatment for skin cancer today. This procedure is an exact and precise method of tumor removal in which the physician serves as surgeon, pathologist, and reconstructive surgeon. It relies on removing the cancer in stages, one tissue layer at a time and visualizing the tumor with a microscope to trace and ensure removal of the skin cancer down to its roots. The goal of the procedure is to precisely identify and remove the entire tumor, leaving healthy tissue unharmed, thus minimizing the chance of regrowth, and lessening the potential for scarring or disfigurement. It is most often used in treating two of the most common forms of skin cancer: basal cell carcinoma and squamous cell carcinoma.

Mohs surgery is name after Dr. Frederic Mohs, professor of surgery at the University of Wisconsin, who developed the surgical technique back in the 1930s. Since then, it has undergone many refinements and has come to be known as “Mohs micrographic surgery” or simply “Mohs surgery” in honor of Dr. Mohs.

• Do not stop any of your medications, including blood thinners, unless you are directed to do so by your physician who prescribed these medications.
• One week prior to surgery, avoid supplements of vitamin E, ginkgo, ginger, garlic, ginseng, and feverfew, which can thin the blood. Three days before and after the surgery, avoid alcohol, which is a mild blood thinner.
• The day of surgery, you may eat your usual breakfast.
• Please take a shower the morning of the surgery and clean the surgical site and surrounding area well with antibacterial soap and water.
• Do not wear makeup or apply lotions or creams on or around the area to be treated.
• Please wear comfortable clothing, preferably a two-piece outfit.
• Due to limited waiting room space, please bring only one person with you.

Patients with pacemakers or defibrillators should notify the doctor in advance of their surgery. If you are unable to keep your appointment, please notify us within 48 hours and make sure to reschedule your appointment.

Most procedures are completed in 1 to 5 hours, depending on how much needs to be done. Surgery is performed using a local anesthetic usually at a single visit. Most tumors require 1 to 4 stages for complete removal.

There will be a one to two hour wait between stages during which each small layer is meticulously examined for remaining cancer cells. During this time, the patient can wait comfortably with a simple bandage in place. We recommend you bring a snack or lunch and some reading material.

Because Mohs surgery is an outpatient procedure and uses local anesthesia, you will be able to drive yourself home or to work after your procedure. If your cancer is near the eyelid skin, you may prefer to have someone else drive you.

Dr. Giuffrida usually recommends not returning to work the day of the surgery and preferably the following day but exceptions can be made.

1. Dr. Giuffrida administers a local anesthetic at the site of the cancer.
2. Dr. Giuffrida removes the visible tumor with a surgical instrument. He removes a thin layer of tissue with a small margin around the tumor site – this is called the 1^ststage.
3. Dr. Giuffrida makes a map or drawing of the tissue. This is used as a guide to determine the precise location of any remaining tumor cells.
4. Dr. Giuffrida takes the tissue to his lab area which is within his office. The tissue is sliced into very thin layers and then mounted on microscope slides by a technician. These are then stained to help see the tissue better. There is typically an one to two hour wait between stages in which the patient can wait comfortably with a simple bandage in place.
5. The entire margin of the tissue is thoroughly examined with a microscope by Dr. Giuffrida to check for evidence of remaining cancer cells.
6. If Dr. Giuffrida finds any cancer cells, he returns to the specific area of the tumor and removes another thin layer of tissue from the area where the cancer cells remain.
7. The removed tissue is again processed in the lab and examined by Dr. Giuffrida with the microscope.
8. If microscopic analysis still shows evidence of disease, the process continues layer by layer until the cancer is completely removed. Once there are no further cancer cells seen with the microscope, the patient is evaluated to determine the best option to help the area heal. Because this systematic search reveals the complete “roots” of the skin cancer, Mohs surgery offers the highest chance of complete removal of the cancer while sparing nearby normal tissue.

The Mohs surgeon uses conventional surgical instruments and removes malignant tissue during surgery.

The difference is what happens to the tissue after it is removed. The specific technique of tissue examination used in Mohs surgery is unique. Although other surgical specialists may check excision margins, this form of pathologic examination of the tissue is not the same as Mohs surgery.

In other therapies, the physician must make an educated visual estimate about the size of the tumor and the margins outside the tumor that must be removed for safety. This may prove ineffective and can lead to having to repeat the procedure soon after or the return of the tumor later on.

It offers the highest potential for cure – up to 99% for new skin cancers and 95% for cancers that have already been treated.

Mohs surgery has the highest cure rate and is primarily used to treat basal cell and squamous cell carcinoma but can occasionally be used to treat less common tumors.

Mohs Surgery is indicated when:

• The cancer is in an area where it is important to preserve healthy tissue for maximum functional and cosmetic result, such as eyelids, nose, ears, or lips.
• The cancer was treated previously and has come back.
• Scar tissue exists in the area of the cancer.
• The cancer is large.
• The edges of the cancer cannot be clearly seen.
• The cancer grows rapidly or uncontrollably.
• The cancer exhibits aggressive pathology under the microscope.
• The patient is immunosuppressed (such as those with organ transplants or lymphoma).

The entire procedure usually lasts between 1 to 5 hours. If you have a consultation with the Dr. Giuffrida prior to your procedure, he may be able to give you a clearer estimate as to the extent of the timeframe for your surgery.

Yes. Any surgical treatment for skin cancer will leave a scar. A benefit of Mohs surgery is that it removes only the cancerous cells and preserves as much normal, healthy skin as possible, which helps to minimize scarring.

Surgical scars improve with time and can take up to 1 year to fully mature. Redness, bumpiness, and hardening of the scar can occur, but these are usually a normal part of healing and resolve with time. Dr. Giuffrida is available throughout the healing process.

Dr. Giuffrida and you will determine how the wound will heal best after the cancer has been removed. Dr. Giuffrida is highly skilled in reconstructive surgery for repairing wounds.

Usually, the surgical area is reconstructed with sutures to try to achieve the best possible cosmetic and functional results. This is typically done the same day as the cancer removal. Stitches can be used primarily in three main ways:

1. Direct closure of the wound in which edges are sutured together side to side.
2. Skin grafting, in which skin is removed from another area of skin and is then placed over the surgery site wound.
3. Skin flap is closing the wound with skin adjacent to the wound.

In certain cases, the wound following Mohs surgery may be allowed to heal on its own. On rare cases, Dr. Giuffrida may refer the patient to another reconstructive surgical specialist.

After Dr. Giuffrida has determined that your skin cancer has been removed, reconstruction and healing of the treated area is also important. Together, Dr. Giuffrida and you will determine how the wound will heal best. Dr. Giuffrida is highly skilled in reconstructive surgery for repairing the wound. Usually, the surgical area is reconstructed with sutures to try to achieve the best possible cosmetic and functional results. This is typically done the same day as the cancer removal. In certain cases, the wound may be allowed to heal on its own. On rare occasions, Dr. Giuffrida may refer the patient to another reconstructive surgical specialist.

Most patients have only minimal pain after surgery. A normal dose of Tylenol can relieve most discomfort.

Some redness, swelling, and/or bruising is normal (especially around the eyes), and it gradually decreases in about one week. Bruising goes away in one to two weeks.  However, should you experience severe pain or sudden swelling, you should call our office immediately to notify us.

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