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Micrographic Surgery for Skin Cancer

What You Need toKnow About

About Dsire Ratner, MDDsire Ratner, MD, completed a two year fellowshipin Mohs micrographic surgery and is a Fellow of theAmerican College of Mohs Micrographic Surgeryand Cutaneous Oncology. She has performed over10,000 Mohs surgical cases and is nationally andinternationally recognized as an expert in Mohsmicrographic surgery.

Dr. Ratner is a fellow of the American Society ofDermatologic Surgery and the American Academy ofDermatology. She is also a member of the Associationof Academic Dermatologic Surgeons. Dr. Ratner isthe only fellowship-trained Mohs surgeon on the fulltime staff at Beth Israel Medical Center. She is theDirector of its Comprehensive Skin Cancer Program,and Director of Dermatologic Surgery. Her trainingand expertise provide our patients with the highestquality of care in the treatment of skin cancer.

What happens after the surgery is over?You will go home with a pressure bandage overthe surgical site, which will remain in placefor 24 to 48 hours. After the bandage has beenremoved, you or a family member or friend willperform wound care to the site, which is quitesimple to do, twice daily. All wound care instruc-tions will be discussed with you and given to youin written form after the surgical procedure hasbeen completed.

Stitches are normally removed in the Mohssurgeons office in one to two weeks. After thestitches have been removed, butterfly tapes (alsoknown as Steri-strips) are placed over the surgicalsite and are left in place until they fall off, usuallytwo days to two weeks later. These tapes provideextra support to the wound after the stitches havebeen removed. While most patients are back totheir normal activities after two to three weeks, it

is important to remember that surgical woundstake six to twelve months to evolve completely.Your surgeon will most likely want to see youapproximately one month after surgery, and maysee you once or twice thereafter to make certainthat you are healing properly. She will then sendyou back to your general dermatologist for regularskin checks.

How do I choose a MOHS surgeon?Your Mohs surgeon should be a member of theAmerican College of Mohs Micrographic Surgeryand Cutaneous Oncology. This means that yourMohs surgeon is a dermatologist who has com-pleted a minimum of one year of comprehensivefellowship training in Mohs micrographic surgery,during which s/he has performed or assistedin a minimum of five hundred cases. If you areconsidering Mohs surgery as an option fortreating your skin cancer, be certain to ask yourphysician about his/her fellowship training andascertain whether s/he is a member of theAmerican College of Mohs Micrographic Surgery

and Cutaneous Oncology.

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If cancer cells are found under the microscope, thesurgeon marks their location onto the map andreturns to the patient to remove another layer of skinbut only precisely where the cancer cells remain.

The removal process stops when there is nolonger any evidence of cancer remaining in thesurgical site. Because Mohs surgery removes onlytissue containing cancer, it ensures that the healthy

tissue is kept intact.

The visible portion of the tumor is surgicallyremoved. Removed tumor is divided into segments,each of which is carefully oriented on a map.The undersurface and edges of each section arethen microscopically examined for evidence ofremaining cancer.

The roots of a skin cancer may extendbeyond the visible portion of the tumor.If these roots are not removed, thecancer will recur.

What is MOHS Micrographic Surgery?Mohs micrographic surgery is named afterFrederic E. Mohs,who first developed the procedureas a medical student in the 1930s. This technique,which came into widespread use in the 1970s,is a specialized surgical procedure used to removeskin cancers, usually basal cell carcinoma andsquamous cell carcinoma.

Why is Mohs micrographic surgery thetreatment of choice for skin cancer?

Of all the treatments for skin cancer, Mohsmicrographic surgery offers the highest cure rate(up to 99%) and the lowest chance for regrowth.It minimizes the potential for scarring and is themost exact and precise method currently availablefor removing skin cancer.

Why is Mohs surgery different fromother treatments for skin cancer?

Skin cancers often have roots that are not visibleto the naked eye but are visible microscopically.Mohs surgery combines surgical removal of theskin cancer and a very narrow margin of tissuesurrounding it with an immediate microscopicexamination. This specialized surgical techniqueallows 100% of the margin around and underthe skin cancer to be examined microscopically tomake certain that all of the roots have beenremoved. It is the only technique available that

ensures that all of the skin cancer is removedwhile sparing normal, healthy tissue to thegreatest degree possible.

What can I expect on theday of surgery?

Mohs surgery is performed in the outpatientsetting under local anesthesia. The area of the skincancer is marked with a sterile marker and numbedwith a very tiny needle. This area is then scrapedwith an instrument called a curette. The curette is a

scraping tool that takes advantage of the fact that

skin cancers are softer than the surrounding skin.When the skin cancer is scraped with the curette,many of the cancer cells scrape away, while thenormal tissue does not scrape away at all. Thisallows the margins of the skin cancer to be moreclosely estimated. The skin cancer is then removedwith a very narrow margin of normal-appearingskin around it.

The Mohs surgeon creates a map of theremoved tissue to be used as a guide to the pre-cise location of the cancer cells, and then sends thespecimen to the lab for processing, which may takeseveral hours. A temporary bandage is placed overthe wound, and you will be escorted to the Mohssurgery waiting area, where you can read, relax, orhave something to eat or drink.

How long will the surgery take?After the lab has processed the tissue, the Mohs

surgeon will look at your slides under the micro-scope. If any skin cancer remains, the Mohs sur-geon will take another thin layer of tissue onlyfrom the specific area where the cancer cells weredetected. That tissue will again be processed sothat the area can be microscopically examined forcancer cells. This procedure continues layer by layeruntil the skin cancer is completely gone. It maytake anywhere from two hours to six or sevenhours to complete this process, particularly if morethan one layer of tissue needs to be removed.While most patients go home by lunchtime, othersmay occasionally need to remain in the office untilthe late afternoon or early evening if more tissuerequires processing.

After the skin cancer has been removed, thesurgical wound will most likely be repaired withstitches under local anesthesia. Every effortwill be made to hide the incision lines within thenatural lines of the face to achieve the bestcosmetic result possible. If the wound is small, itmay be allowed to heal on its own. Larger or morecomplicated defects may require repair by another

surgical specialist.