If you have been referred to have the advanced treatment with the MOHS or Frozen section microscopic controlled removal of your skin cancer, this procedure is most often used in treating two of the most common forms of skin cancer: Basal Cell Carcinoma and Squamous Cell Carcinoma.
This is available and offers the highest potential for cure while minimizing the cosmetic impact – even if previous treatments have failed. Not all treatments for skin cancer are equal. At our office, Dr. Mejia performs the Mohs and the plastic surgery reconstruction. He has been trained in plastic surgery techniques during his residency by plastic surgeons.
Here is a video of one of our patients who had Mohs skin cancer surgery and reconstruction:
What Can You Expect from MOHS or Frozen Section Surgery?
Quick Resolution, Rapid Recovery – Peace of Mind. MOHS micrographic surgery is usually performed on an outpatient basis, under local anesthesia. The healing process is similar to that of most surgical procedures. Your visit will likely last an average of 3-4 hours or it may take all day for large or extensive skin cancers due to the meticulous nature of the procedure. It will be explained below.
Diagnosed with skin cancer?
While you may be frightened, you are not alone. More than 1.2 million people in the United States are diagnosed with skin cancer each year, and most have probably felt the same way you do. A diagnosis of skin cancer is a cause for concern. If left untreated; the disease can continue to progress. However, it is not a cause for panic. Skin cancer is not necessarily life threatening nor does its therapy have to be disfiguring. The most common form of skin cancer, Basal Cell carcinoma generally poses no health risk or spread to other areas of your body.
Options for Treatment:
- Why MOHS? MOHS procedure is a microscopically controlled technique. It removes all the cancer and preserves as much healthy tissue as possible. It provides you with the highest cure rate and least chance of reoccurrence.
- Curettage or ED&C – scraping and burning away of diseased tissue with Electrodessication – or an electric current/ cautery. This tends to leave a round scar which is not usually cosmetically acceptable on the face and does not provide a higher cure rate like the MOHS surgery technique.
- Cryosurgery – freezing diseased tissue with liquid nitrogen. Cannot adequately evaluate the margins or extent of the skin cancer. This may leave a round white scar at the treated area.
- Radiation therapy – Most skin cancers may require 5000 radiation units (Rads). These are divided into treatments of 200-500 Rads each visit. Consequently, it may require several treatments to the hospital.
- Standard surgical excision – Good for areas on the trunk, arms or legs where larger amounts of normal tissue can be removed safely with wide margins. These common treatment methods are often not successful on areas such as the face because they rely on the human eye to determine the extent of the cancer. These methods can remove too little cancer, which could cause it to recur and require additional surgery, or loss of too much healthy tissue, which could cause unnecessary scarring.
Once a cancer has been treated by one of these common methods above other than Mohs and it recurs, the chances of it being cured when treated again by one of these methods becomes less likely. The scar tissue surrounding a recurrent cancer makes it extremely challenging to differentiate between healthy skin and cancerous tissue and further complicates the determination of how much tissue to remove. Consequently, MOHS surgery allows Dr. Mejia a broad certified dermatologisttrained in MOHS surgery to see beyond the visible disease and precisely identify and remove the entire tumor.
Step 1. The suspected area of the skin cancer will be examined and circled to outline the obvious clinical margin visible to the physician or nurse. 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.
Step 2. The visible portion of the tumor is surgically removed. Patient is bandaged and placed in waiting room.
Step 3. A thin layer of normal appearing skin is then removed and divided into sections. The surgeon Dr. Mejia then color codes each of these sections with dyes and makes reference marks on the skin to show the source of these sections according to the numbers of a clock. A map of the surgical site is then drawn and correlated to the specimen removed.
Step 4. The undersurface and edges of each section are then microscopically examined for evidence of remaining cancer. The processing of the specimen can take 30 minutes – 2 hours to process. If you are interested in seeing how this is done, please notify our staff and we will try to accommodate your needs.
Step 5. If cancer cells are found under the microscope, Dr. Mejia marks their location onto the “map”. The patient is returned to the surgical room to remove another layer of skin – but only precisely where the cancer cells remain.
Step 6. The removal process stops when there is no longer any evidence of cancer remaining in the surgical site.
Plastic Surgery Reconstruction:
This will begin once the above steps have confirmed that all the skin cancer roots have been removed. Because MOHS/frozen surgery removes only tissue containing cancer, it ensures that the healthy tissue is kept intact. Dr. Mejia is a board certified dermatologist and has training in plastic reconstructive surgery; he has extensive knowledge of the skin and its healing properties, which helps produce the best cosmetic result. Most dermatologist and MOHS surgeons will perform the reconstructive surgery necessary to repair the wound at the time of the surgery. At our location the cancer excision and plastic surgery is done on the same day. You will not need to travel to another office for the repair.
While all of the above procedures are considered effective and standard for some skin cancers, MOHS micrographic surgery should be the treatment of choice when:
- the cancer is large
- the edges of the cancer cannot be clearly defined
- the cancer is in an area of the body, such as the face, where it is important to preserve healthy tissue
- for maximum functional and cosmetic result (eyelids, nose, ears, lips),·areas that are likely to recur if treated by other methods prior treatment has failed
You should be aware of the benefits and drawbacks of the above options and discuss these with Dr. Mejia in order to choose a treatment that will remove all the cancer, minimize the risk of recurrence, and leave as little scarring as possible. When considering options, or to understand why previous treatment may have failed, it is important to recognize that the tumor that is visible to you – even to your physician – may be just the “tip of the iceberg.” It is why we recommend the MOHS technique to assure complete removal.
Iceberg analogy: Not all cancer cells are apparent to the naked eye. Many “invisible” cells may form roots or “fingers” of diseased tissue that can extend beyond the boundaries of the visible cancer (see black area in the drawing below). If these cancer cells are not completely removed, they can lead to regrowth and recurrence of the tumor. Types of cancer most likely to form these complicated root systems are those that are located in cosmetically sensitive or functionally critical areas. These include areas around the eyes, nose, lips or scalp which can grow rapidly and/or uncontrollably.
MOHS micrographic surgery is state-of-the-art treatment for skin cancer in which the physician Dr. Mejia serves as surgeon, pathologist and plastic reconstructive surgeon. In some cases a separate board certified pathologist assist in reading the microscopic pathology slides to assure all roots of the skin cancer have been removed. While the MOHS procedure may be the same, this has typically been called frozen section surgery because both the dermatologist and the pathologist work together. It relies on the precision and accuracy of a microscope to trace and ensure removal of skin cancer – down to its roots.
Of all treatments for skin cancer, MOHS surgery offers the highest cure rate (up to 99% based on data for treating basal and Squamous Cell carcinomas). It has the lowest chance of regrowth, minimizes the potential for scarring or disfigurement and is the most exact and precise means of removal. For decades, MOHS micrographic surgery has proven effective in getting to the roots of skin cancer by combining the surgical removal of cancer with the immediate microscopic examination of the tumor and underlying diseased tissue.
Options for repair:
Depending on the size and extent of your skin cancer, the resulting defect or area to be repaired could be small or large. Dr. Mejia will help determine what the best recommendation would be in your case.
- Granulation or healing by secondary intention is when the defect is left to heal by itself, and no repair is done. This is best reserved for concave areas that are small. It will take longer for the wound defect to heal (approx. 1-2 months).
- Primary Closure – is reserved for small defects where the skin can be closed side to side without any distortion of adjacent structures such as the eyelid, nose or mouth.
- Flap – This is movement of an adjacent area of skin to cover a defect area. There are many different types of flaps that can be used and will depend on the location and size. An example of a transposition flap is noted on the diagram to the right. Dr. Mejia will determine which type of flap will suit the location and reconstruction if indicated.
4. Graft – A graft is when skin from a completely different area is removed, trimmed to size and placed in the defect area. For example, a specific sized piece of skin can be removed from any of the common donor locations on the diagram to the left in order to cover a defect from another area, such as the nose or the ear. Your surgeon will determine the best donor site for color and texture match.
After your Treatment – Remember that the diagnosis of skin cancer does require you to make some changes to protect your skin, but these changes don’t have to be drastic. The following precautions can help reduce the likelihood that additional skin cancers will develop and will ensure their early detection.
- Protect yourself from the sun. Know your ABCDE’s of Melanoma.
- Be aware of any new/existing lesions on your skin that appear to be changing. If any changes occur schedule a follow up evaluation with our office.