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Mohs Skin Cancer Surgery


What is Mohs Micrographic Surgery?

Mohs micrographic surgery is a specialized, highly effective technique for the removal of skin cancer. The procedure was developed in the 1930’s by Dr. Frederic Mohs at the University of Wisconsin and is now practiced throughout the world. Mohs surgery differs from other skin cancer treatments because it permits the immediate and complete microscopic examination of the removed cancerous tissue. This way, all the “roots” and extensions of the cancer can be eliminated. Due to the methodical manner in which tissue is removed and examined, Mohs surgery has been recognized as the skin cancer treatment with the highest reported cure rate.


Special Qualifications of the Mohs Surgeon

Physicians performing Mohs surgery should have specialized skills in dermatology, dermatologic surgery, dermatopathology, and Mohs surgery. Basic and advanced training in Mohs surgery is available through selected Residency programs and specialized fellowships. In addition, the Mohs surgeon must have the required surgical and laboratory facilities and must be supported by a well-trained Mohs nursing and histotechnological staff. Dr. Shvartzman can provide you with detailed information regarding his training in the discipline, as well as all applicable professional affiliations.


Advantages of the Mohs Surgical Procedure

Some skin cancers can be deceptively large – far more extensive under the skin than they appear to be from the surface. These cancers may have ‘roots” in the skin, or along the blood vessels, nerves, or cartilage. Skin cancers that have recurred following previous treatment may send out extensions deep under the scar tissue that has formed at the site. Mohs surgery is specifically designed to remove these cancers by tracking and removing the cancerous “roots”. For this reason, prior to Mohs surgery, it is difficult to predict precisely how much skin will have to be removed. The final surgical defect could be only slightly larger than the initial skin cancer, but occasionally, the removal of deep “roots” of results in a sizeable defect. The patient should bear in mind, however, that Mohs surgery removes only the cancerous tissue, while normal skin is spared.


Special Indications for Mohs Surgery

It is important to note that Mohs surgery is not appropriate for the treatment of all skin cancers. Mohs micrographic surgery is typically reserved for those skin cancers that have recurred following previous treatment, for cancers that are at high risk for recurrence, as well as large and indistinct tumors. Mohs surgery is also indicated for cancers located on the nose, ears, eyelids, lips, hairline, hands, feet, and genitals. In these areas, maximal preservation of healthy tissue is critical for cosmetic or functional purposes.


The Mohs Surgical Procedure

Typically, Mohs surgery is performed as an outpatient procedure in the physician’s office. Although the patient is awake during the entire procedure, discomfort is usually minimal and no greater than it would be for more routine skin cancer surgery. The Mohs surgical procedure is illustrated in the following diagrams:

Figure A

The area to be treated is cleansed, marked, and injected with a local anesthetic. The Mohs surgeon removes the visible cancer, along with a thin layer of additional tissue. (Stage I). This procedure takes only a few minutes, and the patient waits while the tissue is processed.

Figure B

The removed tissue specimen is cut into sections, stained, and marked on a detailed diagram (Mohs map).

Figure C

Tissue is frozen on a cryostat, and the technician removes very thin sections from the entire edge and undersurface. These sections are then placed on slides and stained for examination under the microscope. (This is the most time-consuming portion of the procedure, often requiring one hour or more to complete).

Figure D

The Dr. Shvartzman carefully examines the entire undersurface and complete edge of the specimen, and all microscopic “roots” of the cancer are precisely identified and pinpointed on the Mohs map. Upon microscopic examination, if residual cancer is found, the Dr. Shvartzman utilizes the Mohs map to direct the removal of additional tissue (Stage II). Note that additional tissue is removed only where cancer is present.

Figure E

This process is repeated as many times as necessary to locate any remaining cancerous areas within the tissue specimen (Stage III, Stage IV, ect.).

Figure F

When microscopic examination reveals that there is no remaining tumor, the surgical defect is ready for repair.


Insurance Coverage for Mohs Surgery

Most insurance policies cover the costs of Mohs surgery and reconstruction of the resultant surgical area. Please contact your insurance carrier directly for the most current payment information relative to this surgery. If you have any questions regarding charges, do not hesitate to contact the billing department at (904) 923 – 6647.


Patient Preperation for Surgery

If you are taking prescription medications, continue to take those unless otherwise directed by a physician. However, you should inform Dr. Shvartzman if you are taking bood-thinners such as Coumadin, Plavix, Aspirin, Aspirin substitutes (such as Advil, Motrin, Nafton, Naprosyn, ect.), vitamin E, gingoko, garlic, ginseng, ginger, ephedra or other nutritional supplements. These medications and supplements can sometimes cause an increased bleeding after surgery. It is important that you obtain a good night's rest and eat normally on the day of your surgery. For your comfort, it is also recommended that you wear casual, layered clothing. You may also wish to bring a light snack and a book or magazine to help occupy your waiting time. It may also be advisable to arrange for someone to drive you home following your surgery.


Duration of Procedure

Most Mohs cases can be completed in three or fewer stages, requiring less than four hours. However, it is not possible to predict how extensive a cancer will be, as the extent of a skin cancer’s “roots” cannot be estimated in advance. Therefore, it is advisable to reserve the entire day for this surgical procedure, in case the removal of additional layers is required.


Minor Post-Surgical Discomfort Expected

Most patients do not complain of significant pain. If there is some discomfort, normally Tylenol is usually sufficient for relief. However, stronger pain medications are available and will be prescribed when needed. You may experience some bruising and swelling around the wound, especially if surgery is performed near the eye.


Post-Surgical Reconstruction

Reconstruction will be performed entirely by Dr. Leonard Shvartzman, who has experience with over 90,000 surgical cases and is well known and respected in the community for his meticulous closures.

If your wound requires care at home, you will be given detailed instructions following your surgery.

For small postsurgical sites, direct closure by suturing the sides of the wound together may be possible. However, in certain areas of the body, there is very little tissue that can be stretched for coverage of a wound and either a skin graft or skin flap may be used. In closing wounds with a flap, the skin adjacent to the surgical defect is partially cut free, and then rotated or moved forward to cover the surgical area. Stitches are then placed to hold the flap in it new position. This provides immediate coverage for the wound. Other areas may require a skin graft tfor coverage. Skin from the side of the neck, behind the ear, or over the collarbone may be cut free, placed over the wound, and then sewn into place. The original site of the graft is closed with stitches.


Wound Healing, Scarring, and Scar Revision

As with all forms of surgery, a scar can remain after the skin cancer is removed and the surgical area has completely healed. Mohs micrographic surgery, however, will leave one of the smallest possible surgical defects and resultant scars. Dr. Shvartzman has extensive experience in closing even the most complicated defects often resulting in scars that are barely noticeable. Even following extensive surgery, results are usually quite acceptable. Scars do have the ability, through the body’s own natural healing properties, to remodel and improve in appearance for a six to twelve month period. There are many other techniques available to the patient for enhancement of the surgical area following skin cancer surgery but this is seldom required.


Potential Complications Associated with Mohs Surgery

Patients should understand there is no guarantee that a surgical procedure will be totally free of complications or adverse reactions. Mohs surgery and reconstruction are no exceptions. During surgery, tiny nerve endings are cut, which may produce a temporary or permanent numbness in and around the surgical area. If a large tumor is removed or extensive surgery is required, a nerve or muscle may be cut resulting in temporary or permanent weakness in a portion of the face. This is, however, an unusual complication. The surgical area may remain tender for several weeks or months after surgery, especially if large amounts of tissue were removed. Rarely, some patients experience intermittent itching or shooting pain in the surgical scar. Infection and hematoma can occur. In addition, skin grafts and flaps used to cover surgical defects may not survive, requiring additional repair.


Leonard Shvartzman, M.D.




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