Basics of Mohs Micrographic Surgery

Mohs micrographic surgery combines surgical excision of skin cancer followed by immediate microscopic examination of the entire lateral and deep margin of the tissue specimen and reconstruction of the resulting defect. All steps of the procedure take place right in the office. Dr. Reszko is a board certified Mohs surgeon.

Mohs Micrographic Surgery consists of the Following steps:

1. Numbing the skin with a local anesthetic and surgical removal of a thin layer of skin containing the tumor.
2. Dividing the tumor-containing specimen into slices that are numbered, mapped, color-coded in precise orientation corresponding to tumor’s location on the patient’s body.
3. Tissue processing in the Mohs laboratory. Tumors containing tissue slices are frozen, sectioned and stained in our Mohs lab.
4. Dr. Reszko examines each section under the microscope to determine if a tumor is present or absent on lateral and deep margins of the removed specimen. This allows complete evaluation of the margin, so called “complete margin control”.

The center of the tissue specimen is not examined because the tumor has already been diagnosed by the prior biopsy and the center of the specimen is not helpful for margin control. If the tumor is removed completely, the skin defect is ready to be repaired. If the specimen is positive for a residual tumor, steps 1 through 4 are repeated until the skin is clear of the tumor.

This detailed examination of the entire lateral and deep margin by Mohs Micrographic Surgery differs from all other pathology techniques. If you have a skin cancer excised by a physician in the office or hospital, the tissue specimen will be sent to a pathology laboratory for processing and examination by a pathologist.

The Mohs Surgery technique allows Dr. Reszko to examine 100% of the surgical margin and, if a tumor is still present, pinpoint the exact location of the residual cancer. This enables the Mohs surgeon to return to the treatment area and selectively remove another layer of skin from the positive area only. This minimizes the amount of normal skin that is removed and therefore creates the smallest possible defect in the skin. Guessing the location of residual tumor in the skin is completely eliminated with Mohs Surgery. Since many of the skin cancers removed with Mohs Surgery are complicated, multiple stages are often required to clear the tumor.

We ask that you please be patient as examination of each of your stages takes up to 20 to 40 minutes. If multiple stages are taken, the Mohs procedure can take up to several hours.

In summary, the use of Mohs Surgery significantly increases the chance of complete cure and reduces the unnecessary sacrifice of surrounding normal skin. This minimizes the size of the surgical defect, makes it easier to repair the defect, and will result in a smaller scar.

Advantages of Mohs Micrographic Surgery

• Procedure (surgery, microscopic examination, plastic surgery reconstruction) performed from start to finish by a skin cancer expert
• Highest cure rate available for skin cancer
• Visualizes 100% of margin of excision (both deep and lateral margins) vs. 1% with standard pathology
• Smallest amount of normal skin is removed
• Smallest possible surgical defect created by Mohs Micrographic Surgery results in smallest possible scar
• More likely to preserve cosmetics and function of treated area
• Reconstruction performed immediately after tumor removed
• Procedure all done under local anesthesia in the office setting

How To Prepare For Your Surgery

Please review prior to surgery

• Plan to spend at least 3 hours at the office. Since most of the time will be spent waiting while Dr. Reszko studies the tissue under the microscope. It is helpful to have a book to read.
• If you take doctor-prescribed aspirin, Coumadin or Plavix, please continue usage as normal.
• Unless doctor prescribed, do not take aspirin or aspirin containing medications (Alka-Seltzer, Anacin, Excedrin, Aleve, Bufferin, Emprin Compound, Ecotin, multiple “cold remedies”) and/or Motrin, Advil, Nuprin, Ibuprofen, high dose vitamin E for 2 weeks before and 5 days after surgery. Tylenol or acetaminophen is acceptable to take during this period.
• On the morning of surgery, please eat a normal breakfast. Take all medications that you normally take.
• If you have been given an antibiotic to take before surgery, be sure to take it as directed one hour before surgery.
• Wear a button down or loose fitting (wide neck) shirt if surgery is on the face or head/neck.
• For surgery on legs, wear pants with loose fitting legs or a skirt if possible. Wear loose, comfortable shoes for surgery on the feet.
• Do not apply makeup (if the skin cancer is on your face), perfume, aftershave, or cologne.
• It is helpful to have Extra Strength Tylenol (or acetaminophen) at home, prior to the date of surgery.
• Please inform office staff if you have taken any anti-anxiety medications prior to surgery. If you have taken any anti-anxiety medication, you must have someone available to assist you with transportation to and from the office.
• You may bring an IPod, laptop computer or similar devices to have with you during the surgery.
• If your skin cancer is located in the center of your face, eyelid, or eyebrow area where a bandage will block your vision or impact your ability to wear glasses, please have someone available to assist you with transportation to and from the office.
• If you are unable to keep the scheduled appointment for surgery, please contact our office at least 48 hours in advance to reschedule your surgery appointment.

Post Surgery

• After your surgery, you will be given detailed verbal and written instructions on how to care for the wound.
• If the surgery is on the lips or around the mouth, plan to eat soft foods, avoid drinking through straws and minimize talking for approximately 1 week post surgery.
• If possible, try to have someone available to help you either in person or by phone for the first 24 hours after the surgery.
• Avoid strenuous exercise, bending, straining, stooping, or lifting any heavy objects for the first week after surgery as they can lead to bleeding from one of the stitches. Arrange your schedule in advance to avoid these activities. If there is any unusual swelling, pain, bleeding, or drainage at the surgical site, if you have any question, or in case of an emergency, please contact our office at (646) 759-8449.  Doctors and staff are always available to answer any questions.

What to Expect On the Day of Surgery

After you arrive in the office, one of our nurses will greet you and take you to the treatment room where the Mohs procedure will be performed. They will ask about your medications and allergies.

The treated area will be anesthetized with a local anesthetic (most commonly Lidocaine). This feels like a bee sting and lasts only a few seconds. The numbing medication lasts a few hours, however additional injections may be required for longer procedures. Any subsequent local anesthetic injections are usually painless or much less painful.

After anesthetizing the area, Dr. Reszko will remove a thin layer of skin affected by the cancer. This is called Stage I and represents the first layer of skin that is subsequently mapped, divided, and color-coded. After Stage I is removed, electrocautery (fine electric needle or heat) is used to stop any bleeding. The wound is then bandaged and you will return to the waiting room or stay in the procedure room while a skin sample is being analyzed. While you are waiting, ask for coffee, read a book or magazine, or chat with other patients. While you wait (an average 20-30 minutes), the skin specimen will be processed, stained and examined by Dr. Reszko under the microscope.

If the microscopic examination reveals the presence of skin cancer, Dr. Reszko will repeat the procedure removing only the skin still containing the tumor.  This second layer is called Stage II. The average number of removals required is two to three stages. The Mohs procedure can typically be completed in less than a half-day and is on an outpatient basis.

Once the skin cancer extirpation has been confirmed we will discuss the options to repair the resulting post-Mohs defect. Most often the defect can be closed in a linear fashion with stitches. This turns the circular defect in the skin into a fine straight line (scar). In other cases, a more complex procedure known as a flap or graft may be required to provide the best possible functional and cosmetic result. This decision will depend on the defect size, depth, and location. If the wound is stitched up, the stitches are removed typically one week later. For more information regarding the reconstruction process, please see the section on reconstruction of the defect.

Wound Care Instructions After Skin Surgery

Keep the postoperative bandage in place until showering the next morning. Before showering, remove and discard the bandage. Cleanse your incision with soap and water (not hydrogen peroxide, not alcohol) to remove any drainage and crusting. Pat the wound dry and apply a generous layer of Vaseline, Bacitracin, Bactroban ointment to the incision. Cover the Vaseline, Bacitracin, Bactroban with a non-adherent Telfa dressing. Tape the Telfa dressing in place with paper tape. Continue this wound care once daily until you return for suture removal.

Prescription Medications

Continue your regular medications as you normally would. If you take doctor-prescribed aspirin, Coumadin or Plavix, please continue your prescribed dosage. Unless doctor prescribed, do not take aspirin or aspirin containing medications (Alka-Seltzer, Anacin, Excedrin, Aleve, Bufferin, Emprin Compound, Ecotin, multiple “cold remedies”) and/or Motrin, Advil, Nuprin, Ibuprofen, high dose vitamin E within the first 24 hours following surgery. Tylenol or acetaminophen is acceptable to take during this period for any procedure-related discomfort.

Activity Level Following Surgery

The recommended activity level following the surgery will depend on the location of the skin cancer, the type of post-operative repair and underlying medical status of the patient.

If possible, please spend the first day following surgery relaxing. Surgery performed on scalp and/or face (forehead, nose, cheeks, and eyelids) may result in swelling and bruising around the eyes (black eyes).   Swelling and bruising may increase progressively during the initial 48 hrs post-operatively and resolve over the subsequent 7 to 10 days. To decrease the likelihood of postoperative side effects:

1. Keep your head elevated during the first few evenings with extra pillows if surgery was performed on the scalp and/or face.
2. Apply ice packs (10 minutes of ice application every hour) to the surgically treated area during the first 48 hours to minimize bruising and swelling.
3. Heavy lifting and exercise should be limited until after the sutures have been removed.
4. Showering can be started the morning after surgery. Bathing is allowed if the incision site is not soaked. Pat the wound dry after leaving the shower and reapply the Vaseline and bandage. Swimming should be postponed until after the sutures have been removed.