Mohs Micrographic Surgery Patient Information Dermatology Department The aim of this leaflet is to give you information about Mohs Micrographic Surgery. What is Mohs Surgery? Mohs surgery is a specialised, highly effective technique for removing skin cancers. It was developed in the 1930s by Dr Frederick Mohs in the United States and is now practised throughout the world. Mohs surgery differs from other skin cancer treatments in that it permits the immediate and complete microscopic examination of the removed cancer tissue so that all roots and extensions of the cancer can be eliminated. Mohs surgery has the highest reported cure rate of all treatments for skin cancer. Treating all skin cancers with Mohs surgery is not necessary. Mohs surgery is reserved for skin cancers that grow back after previous treatments, cancers that are at high risk of recurring, or cancers that are located in cosmetic areas where preservation of the maximum amount of normal skin is important. The vast majority of cases are for the commonest type of skin cancer, Basal Cell Carcinoma. Local anaesthetic injections are used to numb the skin at the affected site. The numbness wears off after approximately two hours, so a second set of top-up anaesthetic injections is likely needed before the reconstruction or second stage of Mohs. In half of cases clearance is achieved in the first stage and in the rest, one or several smaller pieces have to be removed to eliminate all the cancerous roots. Who will be doing the Mohs surgery? Physicians who have the training, surgical and laboratory facilities and staff to perform this specialised technique carry out Mohs surgery. The Mohs service was established in 2003 in NHS Tayside. A dermatologist in training may also be involved. Why remove skin cancers with Mohs surgery? Some skin cancers are deceptively large far bigger under the skin than they appear to be from the surface. These cancers may have roots in the skin or along blood vessels, nerves, or cartilage. Page 1 of 6
Also, skin cancers that recur after previous treatments may send out extensions deep under the scar tissue that has formed. Mohs surgery is specifically designed to remove these cancers by treating and removing these cancerous roots. How do I prepare for surgery? Get a good night s rest and eat normally the day of surgery. It is an early start at 8.00am. Bringing some reading material may help pass the time. It is helpful to have someone accompany you for general support and also to drive you home after the skin surgery is completed. Bringing some snacks or soft drinks can help keep up your energy levels. If you are taking prescription medications, continue to take them unless otherwise directed. If you are on warfarin, aspirin or another drug to thin your blood or if you have a bleeding disorder: The Dermatologist who arranged your biopsy (or the Mohs surgeon who often would like to see you for a consultation before Mohs) will advise if you need to stop this treatment or continue taking it as normal. It depends on the individual circumstances and the risk of stopping versus the risk of continuing. Please stop all herbal remedies and over the counter supplements two weeks prior to your surgery. Please remember to bring a list of your medication and your warfarin record card, if you have one, to show the doctor or nurse who is doing your surgery. If you are uncertain, telephone the Dermatology Mohs Secretary on 01382 740019, two weeks before your operation if possible. Remove make-up. You may want to bring a book or magazine with you to occupy your time while waiting for your slides to be processed and examined. Also, you should arrange for someone to drive you home after surgery is completed. Smoking slows down wound healing and there is a greater risk of wound breakdown or infection if you are a smoker. If possible try to stop smoking two weeks before and until one week after your surgery. It is best to minimise alcohol the day before and for a few days after your surgery. What complications may occur following this procedure? It is rare to have any serious problems after this type of surgery, however: Bleeding can occur; it is usually minimal and controlled by the dressing or firm constant pressure for 20 30 minutes (repeat if necessary). If prolonged bleeding occurs, seek medical help phone the dermatology ward or dermatology treatment centre and you will likely be asked to attend for an assessment. Often bruising and swelling may occur, especially if the surgery has been close to your eyes. Page 2 of 6
Your wound may be painful after the local anaesthetic wears off but you can take paracetamol for this. Infection of the wound occurs in approximately 3% of people; if your wound becomes increasingly red, painful and tender or has a discharge after the first three days; please contact the department (ward or treatment centre phone numbers attached) or your GP. As a result of the skin surgery you will have a scar. Scars are permanent and unpredictable. They often become quite red initially, fading with time over a period of several years. Sometimes there are obvious stitch marks and depending on the site of the wound the scar can become thickened or stretched. If the scar feels tight and firm, gentle massage of the scar may help. It is rare for skin surgical wounds to open or break down but can occur at sites of tension this can result in prolonged healing and widening of the scar. Nerves can become damaged during skin surgery, causing numbness, altered sensation and very rarely muscle weakness. The doctor performing the surgery will discuss this with you prior to the procedure. Mohs surgery is extremely successful, however very occasionally (1%) we may need to go on and do another procedure at a later date. Car parking facilities For drivers using SAT NAV systems the post code locator to use is DD2 1UB. Please note this is for SAT NAV use only and not for postal purposes. There is a charge for all parking on site. The tariff is clearly displayed as you enter the car park. The best long term (24 hour) car park to stay in is Car Park 9 and the multi-storey. There is also a shuttle bus service available on weekdays from 9.00am to 5.00pm, between Car Park 9, the multi-storey and the main entrance to the hospital. The main disabled parking area is located in Car Park 7 at the main entrance, with a total of 70 spaces. These spaces are pay and display with a four hour limit. You must display your official blue badge and payment applies. The car parks are the responsibility of Vinci Park, telephone 01382 643969. Will I be able to listen to music? Yes. You may want to bring in either your favourite CD or your IPod to play. We know that personal choice of music can help to relax you during surgery. Will I need more than one injection? Yes, the site to be treated is numbed using local anaesthetic injections. This may cause some discomfort, especially in sensitive areas on the face, but the discomfort is only short lasting. The anaesthetic then lasts for around two hours. Top-ups of anaesthetic injections may be required during the next stages of surgery. Page 3 of 6
How is Mohs Surgery done? There are three steps involved in Mohs surgery. 1. The skin is made completely numb using a local anaesthetic. The visible cancer is removed with a thin layer of additional normal looking tissue both wide and deep. This takes about 30 minutes and the patient may then return to the waiting area. A detailed diagram (a Mohs map) of the removed specimen is drawn. 2. The specimen is colour coded to distinguish top from bottom and left from right. A biomedical scientist freezes the tissue and removes very thin slices from the entire edge and undersurface. These slices are placed on microscope slides and stained for examination under the microscope. This is the most time consuming part of the procedure, requiring up to two hours to complete. 3. The Mohs surgeon will then carefully examine these slides under the microscope. This allows examination of the entire surgical margin of the removed tissue. Any persistent microscopic roots of the cancer can thus be precisely identified and pinpointed on the Mohs map. If more cancer is found on the microscopic slides, the Mohs map is used to localise this allowing removal of additional tissue only where cancer is present. This allows the Mohs surgery technique to leave the smallest possible surgical defect because no guess work is involved in deciding where to remove the additional tissue. Only tissue around the roots and extensions of cancer is removed. What happens after the Mohs surgery is completed? When the cancer is removed, the Mohs surgeon will discuss with you your options. These may include: Allowing the wound to heal naturally, without additional surgery (rarely used, but in individual cases this may be the best option). Reconstruction of the surgical defect/wound repair by Mohs surgeon (most likely outcome) on the same day. The nature of the reconstruction will be discussed with the Mohs surgeon and includes closing the area side to side in a straight line with stitches, making some extra cuts around the defect to bring some neighbouring skin in (this is called a local skin flap) or taking some skin from elsewhere of the same size and stitching it on to the defect a skin graft. Wound repair by the referring surgeon or another reconstructive surgeon in another department on the same day or on a different day (defect would be dressed in the meantime). How long does it take? In straight forward cases, you can be away early afternoon. Sometimes it takes until early evening to finish the whole process. We therefore ask that you reserve the entire day for surgery, in case additional surgical sessions are required. Page 4 of 6
Recovery How will I feel after Mohs surgery following surgery? You may feel tired physically and drained emotionally. Some patients may feel tearful or low in mood following Mohs surgery. It is quite normal to feel this way following surgery and should improve over time with support from family and friends. We can also offer additional support, advice and help if required. Useful references http://www.bad.org.uk/for-the-public/patient-information-leaflets/mohs-surgery http://www.skincancer.org/skin-cancer-information/mohs-surgery Feedback You can share your suggestions, comments and views on NHS Tayside services on our website: www.yournhstayside.scot.nhs.uk/ Contact Numbers: Ninewells Hospital Dermatology Outpatient Department Telephone: 01382 633873 Dermatology Ward 24 (open 24 hours) Telephone: 01382 633824 Perth Royal Infirmary Dermatology Treatment Centre Telephone: 01738 473516 Stracathro Hospital Dermatology Treatment Centre Telephone: 01356 665208 St Andrews Hospital Telephone: 01334 465725 Aberdeen Royal Infirmary Dermatology department Telephone: 01224 554433 Page 5 of 6
Victoria Hospital, Kirkcaldy Dermatology Department Telephone: 01592 643 355 (Extension 28634) Queen Margaret Hospital, Dunfermline Secretary s number 01383 623623 ext 22215 Dermatology ward, Ward 15, Ext. 27015. Raigmore Hospital, Inverness Secretary s direct number 01463 705343 Ward/Outpatient number 01463 704452 Macmillan Skin Cancer Specialist Nurses Telephone: 01382 660111, extension 33667 or page 4673 Developed by Consultant Dermatologists Ninewells Hospital and has been reviewed by patients Revised: 11/2017 Review: 11/2019 LN0963 Page 6 of 6