The board certified Mohs surgeons at Associated Skin Care Specialists are leaders in the field of dermatologic surgery. We offer cutting edge surgical and laser treatments for a variety of conditions including skin cancers; benign lesions of the skin; or disease of the hair or nails. The health of you and your skin is our passion, and we aim to provide the most comprehensive and effective care possible.
SURGERY SERVICES OFFERED
Micrographic surgery or “Mohs” surgery is a technique to effectively remove skin cancers while limiting the damage to surrounding normal skin. This technique was pioneered by Dr. Frederic Mohs over 70 years ago and has undergone adaptations and improvements over time. It now has the highest cure rate for skin cancer. Because this method requires highly specialized training and personnel, a limited number of medical centers are equipped and properly trained to offer such a treatment. The surgeons of Associated Skin Care Specialists are fellowship trained and board-certified in both Dermatology and Micrographic Dermatologic Surgery. All are active members of the American College of Mohs surgery.
Dermatologic surgery is defined as surgery of the skin for either benign or malignant lesions. Dermatologists are the most highly qualified physicians to perform skin surgery. Dermatologic surgeons understand the biology of the skin and the complex process of healing. Our physicians are well trained in the removal of benign lesions such as moles, lipomas or cysts as well as more complicated lesions such as skin cancers. Dermatologic surgeons are also trained in the surgery and treatment of hair and nail disorders.
Laser technology is used to treat a variety of dermatologic conditions. Many of our physicians have special training in the use of lasers. Lasers can be used for the treatment of vascular birthmarks (port wine stains); blood vessels (telangecstasias or varicose veins); freckles; warts; and wrinkles or photoaging from the sun. Many conditions require a series of treatments to achieve the best results. A consultation with one of our laser physicians can help you plan the best treatment for your concern.
SCAR REVISION SURGERY
Scars develop following injury to the skin. While most often scars become barely visible over time, some scars can be more problematic. The appearance and sensation of scars can be improved through a variety of methods including topical agents, therapeutic injections, laser therapy and surgical scar revision.
SKIN CANCER AND MOHS SURGERY FREQUENTLY ASKED QUESTIONS
WHAT IS SKIN CANCER?
Cancer is tissue which grows at an uncontrollable and unpredictable rate. In the skin there are three main forms of skin cancer:
Basal cell carcinoma (BCC) -- the most common and often the least aggressive.
Squamous cell carcinoma (SCC) -- slightly less common than basal cell and at times can become more aggressive.
Melanoma -- one of the more aggressive forms of cancer, often associated with a brown or black color.
Each of these types of skin cancer starts from a different cell type. One type does not become another.
IS IT DANGEROUS?
The most common types of skin cancer, basal cell carcinoma and squamous cell carcinoma, grow locally in the skin. They usually present as a sore that won’t fully heal, or an unusual bump. While it is rare for these types of skin cancer to spread internally or metastasize, they do continue to grow locally. They can invade and destroy adjacent structures like cartilage and bone if left for a longer period of time. Fortunately, they are often slow to invade. Since these skin cancers are visible, they are generally caught in their early stages. Most of these tumors are easily cured.
Malignant melanoma can grow rapidly. It can be life threatening if not treated early. Melanoma usually appears as a brown to black lesion. It may bleed or be tender. Melanoma can develop from a mole that has been present for many years, or it can develop as a brand new lesion.
WHAT CAUSES SKIN CANCER?
Excessive exposure to natural sunlight or ultraviolet rays (like tanning beds), is the single most important factor associated with the development of skin cancers. As such, these skin cancers present most commonly on the areas exposed to the sun -- the face, scalp, chest, arms, and hands -- but skin cancer is not limited to these areas.
A second factor that impacts the risk for skin cancer is your natural skin type or color. Skin cancer is more often seen in those with fair skin types such as Northern European descendants.
Other factors include X-ray exposures, trauma, genetics, and some chemical exposures. There are ongoing studies to investigate other factors and ways to reduce skin cancer risk.
HOW DOES SKIN CANCER START AND HOW DOES IT GROW?
Skin cancer begins in the uppermost layer of the skin and invades downward with extensions of cells or “roots”. These extensions can go both deeper and wider than the apparent lesion on the surface of the skin, thus the actual cancer can be bigger than what you see on the surface. The lesion apparent to the naked eye may actually be only the “tip of the iceberg”.
ARE THERE OPTIONS FOR TREATING SKIN CANCER?
Depending on the location and severity of the cancer there are different methods to remove the cancer. The method chosen depends on the cancer type, the cancer size and location, and if previous treatments have occurred.
If the cancer is located on the trunk (back, chest or abdomen) or the arms and legs and is small, it may be surgically removed and sutured without the micrographic procedure.
Shallow lesions can be treated with laser or curettage and electrodessication (electrical cautery and scraping).
Topical chemotherapy (medications combined in creams) can attack very shallow cancers.
Micrographic surgical removal (Mohs) is commonly used on the head, neck, hands, feet and other sensitive areas, with larger tumors, or with more aggressive subtypes.
WHY IS IT CALLED MICORGRAPHIC OR MOHS SURGERY?
This highly specialized procedure for the removal of skin cancer involves the use of a microscope to directly visualize the margins of the skin cancer being removed, hence the term micrographic surgery. Positive tumor margins are marked on a map to guide the surgeon in further removal of tumor. This technique was originally developed by Dr. Mohs in the 1930’s and therefore carries his name.
WHAT ARE THE ADVANTAGES OF MICROGRAPHIC SURGERY?
The micrographic surgeon can pinpoint with the microscope the areas where there is cancer and selectively remove tissue only from these areas. The entire margin of the tumor is examined with the microscope. In this way the skin cancer is traced out to its roots with little guesswork involved. This allows the removal of as little normal surrounding tissue as possible.
Success rate with the micrographic technique is very high. The cure rate with Mohs surgery is typically 98-99% -- even in cases where other techniques of skin cancer removal have failed. Although this rate is very high, recurrences can occur. Because of this, it is recommended that patients with a history of skin cancer should be seen by a dermatologist annually for skin checks.
Advantages of Mohs surgery:
- Ensures complete cancer removal during surgery, with extremely low recurrence rate.
- Minimizes the amount of healthy tissue lost.
- Maximizes the functional and cosmetic outcome resulting from surgery.
- Repair of the site of the cancer often completed same day as Mohs.
- Cures skin cancer when other methods have failed.
WILL MY INSURANCE COVER MICROGRAPHIC SURGERY?
Depending on your deductible, most health insurance policies cover the total cost of micrographic surgery. Since each policy, with its copay and deductible, is different please check with your insurance company or our business office if you have questions regarding costs and insurance coverage.
WHEN TO SCHEDULE SURGERY?
It is recommended that skin cancers be treated in a timely fashion. When scheduling, please plan to keep your activities light and to rest frequently for the first day or two. Following surgery, you will have limitations with bending, stooping, lifting, and exercise for several days. Please keep these limitations in mind when scheduling.
HOW LONG DOES THE SURGERY TAKE?
The time it takes to remove your skin cancer will be related to the size and complexity of the cancer as well as the location. Total removal of the skin cancer may take several layers. Each layer is an attempt at removal of the skin cancer with minimal involvement of surrounding normal skin. A cancer may be more complex or larger than it appears on the surface. It often takes more than one layer to completely remove the tumor.
After removal of the skin cancer, the tissue is brought to our laboratory. It is normal to expect a 60-90 minute processing time with each layer. The number of layers needed depends entirely on how deep or extensive your skin cancer is. Unfortunately there is no way to determine this prior to your surgery.
After the cancer is completely removed, a decision is made as to the best way to heal the wound created by the removal of the skin cancer. This typically includes closure of the wound with stitches. Coupling the time to repair the wound with the Mohs surgery itself can take much of the day. Please be prepared to spend the day at our clinic.
IS THE SURGERY PAINFUL?
A local anesthetic is injected around the skin cancer to numb the area. Depending on the area involved, the initial injections can be very tender, but goes by quickly. The surgery does cause some discomfort, but no pain should be felt once the anesthetic has been injected. More anesthetic will be added throughout your visit to maintain the numbness of the area and to allow for closing the wound.
WILL SURGERY LEAVE A SCAR?
Yes, any form of therapy will leave a scar. By keeping the removal as small as possible, the micrographic technique tends to minimize the scar as much as possible. Furthermore your surgeon is trained in reconstructive surgery techniques to further minimize the appearance of the scar.
WILL I NEED TO BE HOSPITALIZED?
For the vast majority of patients, the surgery is performed as an outpatient procedure. On rare occasion, we require that the patient stay in the hospital. We will let you know during your first visit if we feel it would be best for you to be hospitalized.
SHOULD YOU TAKE YOUR MEDICATIONS?
Do you take vitamin E, aspirin, Coumadin (warfarin)? Do you take other blood thinners such as Motrin, Ibuprofen, Advil, Bufferin or Naproxen?
If you take aspirin or vitamin E please contact your primary care doctor to see if you can stop these medications. If you are able, please stop these medications at least 7-10 days prior to surgery.
If you take Coumadin (warfarin) or other blood thinners please contact the physician who is managing your medication to determine if you can hold the medication 2-3 days prior to surgery. In some cases, holding Coumadin is not possible. In these cases, an INR between 2.0 to 2.5 is often acceptable but may be adjusted slightly lower if needed.
If you take non-steroidal anti-inflammatories such as ibuprofen (Motrin/Advil) or naproxen (Aleve), please discontinue 5 days before surgery. If you need any pain medication prior to surgery, acetaminophen (Tylenol) is okay to take, as it does not have a thinning effect on the blood.
Please continue to take all of your other prescribed medications.
DO YOU HAVE AN ARTIFICIAL JOINT OR HEART VALVE?
If you have artificial joints or heart valves, please contact your primary care physician about whether pre-operative antibiotics are necessary. Generally, if you are required to take antibiotics before dental procedures you may need to take them before surgery.
WHAT IS A PRE-OP CONSULTATION?
Your first visit, or consultation, is an opportunity for your surgeon to examine your skin cancer and take a pertinent history to determine whether the technique of micrographic surgery is the most suitable treatment. It also gives you the opportunity to learn more about the procedure and ask any questions you may have. Every skin cancer is different. Careful scheduling is necessary to assure the best result.
Occasionally the surgery may be done on your first visit, particularly if you have had micrographic surgery previously. Otherwise a suitable date for surgery that is mutually acceptable will be arranged.
SHOULD SOMEONE COME WITH ME ON THE DAY OF SURGERY, OR WILL I NEED A RIDE HOME?
This may be determined at your consultation. If the surgery is in an area where your sight will be affected, or if it will affect mobility in any way, then you should plan to have a driver. We recommend a driver for larger lesions as well. It also may be more pleasant for you to have company during your long day.
WHAT TO EXPECT ON THE DAY OF SURGERY QUESTIONS
WHAT SHOULD I EXPECT ON THE DAY OF SURGERY?
Appointments for surgery are usually scheduled early in the day. This allows us to complete the surgical steps throughout the day, and minimizes the possibility of having to make another trip to the office the following day to complete the procedure. Please eat a good breakfast on the day of surgery.
Medical support staff will escort you to an operating room where a local anesthetic is used to numb the skin. As the surgery progresses, please be sure to inform your doctor if you experience any discomfort as more anesthesia can be used.
After the lesion is anesthetized, the surgeon will remove the observable cancer with the first layer along with a narrow margin of normal appearing skin. Since cancers can be larger under the surface, the first layer may or may not contain all the cancer. Cautery will be used in the area where the cancer is removed to stop bleeding. You may feel heat from the cautery but should not feel pain. The medical assistant will then bandage the wound and escort you back to the waiting room.
The removed tissue will be processed in the laboratory where thin sections will be made into microscope slides to be analyzed by your surgeon. This is the longest part of the removal procedure and takes about an hour or more. The surgeon will then determine if the cancer was completely removed or if more is still present. If examination of the specimen reveals that your tissue still contains cells of skin cancer, the procedure will be repeated as soon as possible. Several layers, or surgical excisions, followed by microscopic examinations may be required to obtain clear margins and completely remove your cancer.
HOW MANY SURGICAL SESSIONS WILL BE NEEDED?
The average number of surgical sessions is two to three. Most patients are finished by mid-day. Occasionally it will take the whole day.
WHAT IS THE NEXT STEP AFTER MICROGRAPHIC SURGERY IS COMPLETE?
When we have determined that the skin cancer has been completely removed, a decision is made about the wound created by the surgery. Usually there are three choices:
- To allow the wound to heal on its own (granulation or secondary intention)
- To close the wound with layered sutures.
- To close the wound using a skin graft or flap procedure sutured in place.
- Larger or more complex repairs may be referred for outside consultation with physicians specializing in Ear-Nose-and-Throat or Plastic Surgery.
We will recommend which of these choices will be best for your individual case.
CARE AFTER SURGERY QUESTIONS
WHAT WILL I NEED TO DO FOR WOUND CARE?
Wound care instructions particular to your surgical site will be discussed at length with you by your surgeon and the medical support staff. Written instructions will also be sent home with you.
WILL I HAVE PAIN?
Most patients do not complain of significant pain. If there is some discomfort, normally Tylenol alone is required for relief. However, stronger pain medications are available and may be prescribed when needed. You may experience bruising, swelling and small amounts of bleeding around the wound. If any of these are severe, you should contact your surgeon.
WHEN SHOULD I BE CONCERNED?
If you have a foul smelling drainage coming from the wound, fevers or chills, or pain that is increasing at the site rather than improving, please call our office immediately as these may be an indication of a developing infection. You may need to be seen or an antibiotic may need to be prescribed.
If you have excessive bleeding, apply pressure to the wound dressing without releasing for 15 minutes. Then gently lift and check for ongoing bleeding. If two 15 minute attempts at pressure fail to control the bleeding, then call our office. If it is after hours and appears critical, seek immediate medical attention.
HOW SOON WILL MY FOLLOW UP VISIT BE?
If sutures are in place, suture removal will be arranged after surgery. Generally suture removal will be in one to two weeks for areas on the head and neck. For areas on the trunk, suture removal will be between two to three weeks.
If the wound is healing on its own (granulation) this process often takes between 4 to 8 weeks depending on the wound depth and location. Wounds on the scalp and legs tend to take longer. During the initial healing you will need to cleanse the wound regularly and replace the dressing.
If someone will be helping with the dressing changes it may be helpful for that individual to accompany you on the day of surgery in order that we may give instructions on wound care.
HOW OFTEN WILL I BE ASKED TO RETURN FOR FOLLOW-UP VISITS ONCE THE WOUND HAS HEALED?
At your post-surgery visit, your surgeon will recommend the appropriate schedule for future visits if not already arranged by your primary dermatologist. There are several reasons why this is important.
While recurrence is rare, it is most advantageous to detect it when it is still small and easily treated. Experience has shown that the rare cases of recurrence usually occur within the first year following surgery.
Studies have shown that once you develop a skin cancer, there is a higher probability that you will develop others in the years to come. We recommend that you be seen at least once a year for a skin check. This will most likely be with your referring physician. We also recommend that you perform self-skin checks quarterly and inform your physician if you develop any suspicious lesions.