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Skin cancer is not a phrase you ever want to hear, but thankfully there are a growing number of treatment options. If your doctor has recommended surgery, then you might have heard of Mohs surgery. Is this the right choice for you, or should you have traditional wide excision surgery instead? Advocating for yourself involves understanding these options, which one you should pick, and empowering yourself with choices rather than simply following the lead of the professionals.
What is Mohs Surgery?
Mohs surgery is also called Mohs micrographic surgery. It’s named after the doctor who created it, one Frederic E. Mohs, who developed chemosurgery back in the 1930s. His student, Perry Robins, applied it to dermatology and advanced the procedure further.
In Mohs surgery, the surgeon starts by removing a layer of tissue that includes the visible tumor. Then, while the patient waits, the tissue is analyzed to see where remaining cancer cells occur. The wound is covered with a pressure dressing between layers.Then another layer is removed just from that location. When done correctly, Mohs surgery removes all of the cancerous cells while leaving as much healthy tissue in place as possible. Mohs surgery is done under local anesthesia, and you will be awake for the entire procedure, significantly reducing the risk of surgery. However, it can take several hours, with much of that time spent waiting on the lab results between rounds. You will be able to read, watch videos, or engage in other light activity between layers, although you might be there for a while. This is one of the downsides of the procedure, but many patients find it well worth it for the higher success rate.
The wound will then be repaired. Depending on its size or location, the surgeon may use stitches to close the wound. Larger wounds may need a skin flap or skin graft, which may require a plastic surgeon or hand surgeon to assist. However, in most cases, the Mohs surgeon will do the repair and cleanup work themselves. You will receive instructions about recovery and aftercare, including avoiding strenuous activity for a period of time. Small circular wounds can often be allowed to heal on their own, but you should still follow aftercare instructions.
Advantages of Mohs Surgery over Excision
Mohs surgery has a lot of advantages over traditional incision techniques, where the surgeon cuts out the skin cancer. They include:
- Higher success rate. When performed by an experienced surgeon, Mohs surgery has up to a 99% cure rate for previously untreated cancers and 94% for recurring cancers. This rate tends to be higher for cancers other than melanoma, which has a 98% cure rate.
- No general anesthesia. The procedure takes place under local anesthesia. You will be awake, but the procedure is not painful, although some people do experience discomfort from the anesthesia process itself. This makes it a particularly valuable procedure for patients who are at high risk of complications from general anesthesia. It takes place in a clinic or surgical suite, rather than a hospital. You will be able to engage in activities between layers, although you may need to receive more local anesthetic when the surgeon returns.
- Higher preservation of healthy skin, which is particularly important for lesions on the face, hands, feet, or genitals. There is generally a much smaller scar and better cosmetic results. If the lesion is on your face or eyelid, then Mohs surgery may be the only reasonable option other than relying on radiation therapy without surgery, which generally has more side effects and a lower rate of success.
- Most patients have the wound closed and treated the same day, with some wounds healing without stitches. This means it is a same day procedure and you are very unlikely to need to stay in the hospital.
- Reduced risk of recurrence and the need to have another procedure. Excision surgery often has to have a follow up when the tumor comes back, resulting in a second procedure and the associated risk and annoyance. This is much less common with Mohs, although it is never possible to completely prevent recurrence.
Because of these advantages, Mohs surgery is typically preferred for cancers that can be treated with it, and most dermatologists will recommend it when possible. However, it is not suitable for all situations and does have some downsides.
Disadvantages of Mohs Surgery
There are, of course, some disadvantages to this approach, which include:
- Longer procedure time. It does take several hours to complete a Mohs procedure, while some other removal techniques can be done much faster. This may be mitigated by a reduced risk of ending up in the hospital, but if you need Mohs treatment it may take all day. It also may not be possible to predict how long it will take as the surgeon will not know how many layers they need to remove until they have already started the procedure. A simple excision, on the other hand, can take as little as 30 minutes, and patients in less physically demanding jobs can often go straight to work after the procedure.
- Requiring a specialist. Not all surgeons are trained in the Mohs technique. It does require skill and specialist training. You may need to go to a separate clinic that provides the technique rather than getting treatment from your oncologist. Although the fact that it can take place in the office reduces cost, the need for a specialist can make it more expensive, especially for patients in remote areas who may need to travel for treatment. Some dermatology clinics may have a specialist on site who can handle it, or they may be able to refer you elsewhere. But the fact remains that some people are not able to access the treatment even if it would be ideal for them.
- It is not suitable for all types of skin cancer nor is it suitable for all parts of your body. Mohs is typically used to treat basal cell carcinoma or squamous cell carcinoma, and is mostoften recommended for large or aggressive cancers, cancers in areas with little tissue underneath the skin, such as the face or hand, and recurrent cancers. It is sometimes used for melanoma, but this is a variant called slow Mohs where you have to come back each day. Mohs is only recommended for patients with one cancer or a cluster close together. Other patients may need traditional excision surgery or other techniques.
Despite this, Mohs is often better for patients who are eligible for it. Your oncologist or surgeon will discuss your options with you, including cost, and allow you to make an informed choice.
What Types of Tumors Are Best Treated by Excision?
Excision is a better treatment for small, superficial tumors on the abdomen, chest, back, arms and legs. It is easy for your dermatologist to remove these tumors, be sure they got it all, and let you move on. There’s typically no need for general anesthesia or heavy wound repair. Cryosurgery can also work well for these tumors. These tumors are also commonly in areas covered by clothing, where scars are less of a concern. The procedure can be done very quickly in your dermatologist’s office.
Larger tumors may be better served with Mohs if doing so gives a higher chance of removing all the cancer or allows the procedure to be done under local anesthesia. However, Mohs may not work well if the cancer has spread beyond the skin, for example into the lymph nodes. These procedures typically need to be done under general anesthesia in a hospital and may require an overnight or longer stay.
Your dermatologist will discuss your options and refer you to a Mohs surgeon if needed.
Risks Associated with Mohs Surgery
No surgery is without risks, and Mohs surgery can have side effects or complications. The most common complications are:
- Infection at the surgery site
- Nerve damage at the surgery site, causing numbness or a burning sensation. This is typically temporary, but can become permanent.
- Keloids, which are a type of large scar that is raised and red
- Bleeding from the surgery site.
You may need to return to the surgeon for further treatment to deal with bleeding, or take antibiotics to fight infection.
You can reduce your risk of complications by following your surgeon’s instructions for recovery and aftercare. This may include taking antibiotics, cleaning the wound carefully and using antimicrobial solution before dressing the wound, avoiding sun exposure and not wearing makeup if the wound is on your face. If you have had keloids in the past, your surgeon may prescribe a silicone gel formulation to reduce scar tissue growth. If a scar does develop, you can talk to your dermatologist six months after the operation about scar treatment. You should also avoid strenuous activities for one to two weeks after your procedure as this can put strain on the healing wound and result in bleeding.
Risks Associated with Excision Surgery
Excision surgery also has risks associated with it, some of which may overlap. These include:
- Infection at the surgery site
- Nerve damage at the surgery site, causing numbness or a burning sensation. This is typically temporary, but can become permanent.
- Blood clots if you were under general anesthesia, especially if you have a lengthy hospital stay due to other complications. Blood clots can be mitigated by getting up and moving around as quickly as possible.
- Bruising and/or swelling at the surgery site
- Bleeding from the surgery site
- Scarring, which is almost a guarantee with this procedure. Your dermatologist can help reduce scar tissue.
- Chest infection is a risk with larger tumor removal.
- High damage to surrounding tissue, which can worsen scarring, increase downtime, and sometimes affect function.
The risks are, thus, higher, although Mohs surgery is not risk free. Your dermatologist will help you weigh the risks of the two different procedures for your specific situation. With excision surgery you also should follow your surgeon’s instructions about aftercare and downtime. This may be minimal if you only had a very small mole or lesion removed, or significant if you had to have general anesthesia.
Is Chemotherapy or Radiation Needed After Mohs Surgery?
For some patients, yes. Even with Mohs surgery there may be occult (hidden) cancer cells remaining that can result in recurrence. If your skin cancer is particularly aggressive or large, then you may be recommended chemotherapy or radiation to prevent recurrence and ensure that you remain cancer free.
Many patients, however, do not need any further treatment, although you should visit your dermatologist every year to be checked for new skin cancer. Unfortunately, people who have had skin cancer once are at higher risk of getting it again, not necessarily in the same location, so you should have a full check every year, both for recurrence of the cancer and any new tumors.
You should also conduct regular self-examination, looking for new or changed moles, lesions, etc. Talk to your dermatologist about other steps you can take to reduce recurrence and be careful with sun exposure. Because of your risk, you should be particularly careful about wearing high quality sun screen and consider wearing a hat, especially if you have had lesions on your face.
Which Is Best For Me?
There’s no simple answer about what kind of surgery you should have. In addition to excision and Mohs, your dermatologist may discuss cryotherapy or curettage and electrosurgery. The latter may be better than excision for very small, well-defined tumors. Cryosurgery is most often used for precancerous lesions as it does not always prevent spread.
Mohs surgery is typically a good answer for aggressive tumors or ones on areas where skin is close to bone and traditional incision will leave far worse scarring. Because of this, it’s a common procedure for lesions on the face or hands. However, the lengthy procedure is not needed for small, non-aggressive, clean-edged tumors that can easily be removed using excision or curettage.
Always ask your dermatologist why they are recommending a particular course of treatment and what your other options are.