Mohs surgery is a highly specialized procedure used to treat skin cancer while preserving as much normal surrounding tissue as possible. Roswell Park Comprehensive Cancer Center offers highly specialized and innovative treatments for skin cancer including Mohs Micrographic Surgery performed by specifically trained and certified surgeons that remove individual layers of the affected skin until all the cancer is gone.
Listen as Roswell Park Comprehensive Cancer Center’s newest Mohs surgeon, Kimberly Brady, MD, shares more about Mohs Surgery for skin cancer.
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Mohs Surgery for Skin Cancer
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Learn more about Kimberly Brady, MD
Kimberly Brady, MD
Kimberly Brady, MD, is an Assistant Professor of Oncology at Roswell Park Comprehensive Cancer Center.Learn more about Kimberly Brady, MD
Transcription:
Mohs Surgery for Skin Cancer
Bill Klaproth (Host): One of the most common types of surgery when it comes to skin cancers on the face, scalp, hands, and feet, is Mohs surgery. What exactly is it, and is it right for you? Here with us is Dr. Kimberly Brady of the Department of Dermatology at Roswell Park Comprehensive Cancer Center. Dr. Brady, thanks for your time today. What exactly is Mohs surgery?
Dr. Kimberly Brady (Guest): Mohs surgery is a technique – it was developed by Dr. Frederick Mohs in the 1930s at the University of Wisconsin – and it’s essentially an outpatient procedure for removing skin cancers that has a very high cure rate. Skin cancers can have microscopic roots, and it’s important that we get these roots out so that they don’t grow back. We perform a process called Mohs surgery, and we’re basically checking it as we go underneath a microscope. Under local numbing medicine, a skin cancer is cut out, we look at it underneath a microscope, if there’s still tumor present, we go back, and we take more. If it’s not, once the tumor is cleared and all the margins are negative then that area can be repaired and sewn back together.
Bill: It sounds like it’s highly targeted and you go and then you look again, go and look again, and then when it’s all gone, you stop basically?
Dr. Brady: Exactly.
Bill: So by preserving as much normal surrounding tissue as possible, I imagine you get a better cosmetic result then, too, right?
Dr. Brady: Right. Not only do you have a better cosmetic result, but you also get a better functional result as well. As you mentioned before, a lot of the locations that we’re doing the surgery are on the face, the head, the neck, hands, feet, genital areas, so you can imagine that the smaller we keep the defect size, the better function you’re going to preserve the surrounding areas. This is especially important if we’re working around the eyes, the nose, the ears, the mouth, so not only just the cosmetic result, or how it looks afterward, but also the functional result.
Bill: Right, functional, as well. Who is a candidate for this, Dr. Brady?
Dr. Brady: The main skin cancers that we tend to treat are basal cell cancers and squamous cell cancers. Those are the majority of skin cancers that we see, so when these skin cancers are located in the areas that I mentioned before – face, head, neck area, hands feet, genitals – that would be an indication for Mohs surgery. Also, tumors that have recurred, so those tumors that had been treated in the past and now they’ve come back, any large, aggressive, or rapidly growing tumors, tumors where the edges aren’t clearly defined. That means it’s hard to tell where they start and stop with the naked eye so you would need the aid of a microscope. Also, patients who have suppressed immune systems, so we see a lot of organ transplant patients with suppressed immune systems that are at higher risk of developing skin cancers. All of these would be indications for Mohs surgery.
Bill: So there’s a wide variety of benefits and applications for Mohs surgery then? Now you mentioned it is performed as an outpatient procedure. Can you talk about that a little bit? Is this a short procedure? I know it depends on each individual patient, but can you give us a general idea of what that’s like?
Dr. Brady: We tell the patients to block off an entire day with us just because we’re not sure how long each individual procedure will take. Sometimes patients are here for a couple hours, however, if the skin cancer seems to be quite extensive when looking underneath the microscope, they could be here well into the afternoon. We basically tell them that they should at least plan to spend all day with us and not make plans for the rest of the day.
What happens is, usually the patients will come in in the morning and in general, Mohs surgery is done under local numbing medicine. That means that they can eat breakfast before they come, they can have snacks, they can have lunch throughout the day. Most of the time they’re able to take all their normal medications. We may instruct them to stop some, and that just depends on each individuals’ personal medical history. After they get numbed up, the tumor is removed, it’s cut out, and that only takes several minutes, and the patient’s then bandaged, and they have a seat in the waiting room. They can hang out with their family member or friend, or whoever came with them. They can read books, they can watch TV, they can use wifi, whatever keeps them occupied during that time because it usually takes maybe 45 minutes to an hour while the microscope slides are being processed and analyzed. If there is still tumor present, I will mark it on a map, and then I will go back, and I will take more where I need to. If the tumor is clear, then the area can be reconstructed again. If the tumor’s not clear, we have to repeat the process back-and-forth, and every time we check the tumor underneath the microscope, they’ve got another hour or so to wait. Most of the time when the tumor has been cleared, those areas will be repaired by the Mohs surgeon and most surgeons are thoroughly trained in reconstruction techniques. We do side-to-side closures. we do grafts, which means taking skin from one area of the body and using it as a patch over that hole. We do flaps, which means taking adjacent, looser skin, and sliding it into place. Other times, the defect itself is quite small; we can just let it heal in on its own. Once the patient’s reconstructed, once they’re repaired, then they get bandaged up, and then they're discharged for the day.
Bill: After discharge, what is the general recovery time?
Dr. Brady: It's going to depend on how large the tumor was that was removed, and also that area – the part of the body that it was removed from – but in general, I’d say most of my patients have some slight discomfort for two to three days, and that’s usually something that’s amenable to over the counter medications, like acetaminophen, Tylenol. We tell them that for the next one to two weeks – again, depending on where they had the surgery – they shouldn’t do any bending, heavy lifting, exercising, going to the gym. Like any surgical procedure, they’re going to have some redness. They’re going to have some puffiness and swelling. They’re going to have some bruising. All of this is going to resolve over time. I do tell my patients as far as long-term expectations that you can’t cut the skin without leaving a scar. Initially, the surgical site is going to be noticeable, but I tell them also, my goal is at one year if a stranger were to approach them on the street, that stranger should not be able to tell that they had surgery performed.
Bill: Well, that’s very good news, and that’s what everybody wants to hear. Are there any possible risks involved with Mohs surgery?
Dr. Brady: The risks that are involved tend to be bleeding and infection, which is still pretty low. It’s about 2%, but those are the main risks. There’s a small chance that the tumor could recur – Mohs surgery does have a high cure rate, up to 99% for basal cells and squamous cells, but there’s still about that 1% chance that it still could come back. Other risks are because we are cutting through the skin and attempting to remove tumor, it’s going to depend on how wide and how deep that tumor goes that we could be getting into other structures, so maybe nerves, they may be left with some residual numbness. Rarely, they can have some defect as far as movement of the face, but again, it’s going to depend on how deep and how wide we have to go to get that skin cancer out. Most of the time the nerve damage is restricted just to numbness and rarely does it involve any motor function.
Bill: And Dr. Brady, you’ve talked about the cure rate for Mohs surgery. This sounds like it’s highly effective. Can you just spend a little bit of time on that? What’s the percentage again of efficacy on Mohs surgery?
Dr. Brady: Up to 99% for basal cells and squamous cells, and that’s because we’re looking at the entire margin around the area that we remove. We look at 100% of the side margins and 100% of the deep margin, meaning the margin that’s underneath the tumor that we remove.
Bill: So generally, if you have Mohs surgery done, there’s a pretty good chance it’s not coming back again?
Dr. Brady: That’s true, yes. It’s more likely that a patient would develop a skin cancer somewhere else. Once a patient has been diagnosed with a skin cancer, they’re at a higher likelihood of developing a skin cancer elsewhere just because they probably have the risk factors that have set them up for it, sun exposure over the years, fair skin, light eyes, blonde or red hair, a lot of moles. Now they have a personal history of skin cancer, they’ve had a family history of skin cancer, so it’s more likely that they would develop a skin cancer unrelated to the first one, but just related in the fact that they’re a setup to developing skin cancers, so we do recommend that they continue regular, routine skin checks with a dermatologist, just to make sure that nothing’s coming back, they’re not growing anything new, and if they are that the Dermatologist can catch it early.
Bill: Dr. Brady, thank you so much. That’s great information. Thank you for explaining Mohs surgery to us. For more information, visit RoswellPark.org, that’s RoswellPark.org. You’re listening to Roswell Cancer Talk. I’m Bill Klaproth, thanks for listening.
Mohs Surgery for Skin Cancer
Bill Klaproth (Host): One of the most common types of surgery when it comes to skin cancers on the face, scalp, hands, and feet, is Mohs surgery. What exactly is it, and is it right for you? Here with us is Dr. Kimberly Brady of the Department of Dermatology at Roswell Park Comprehensive Cancer Center. Dr. Brady, thanks for your time today. What exactly is Mohs surgery?
Dr. Kimberly Brady (Guest): Mohs surgery is a technique – it was developed by Dr. Frederick Mohs in the 1930s at the University of Wisconsin – and it’s essentially an outpatient procedure for removing skin cancers that has a very high cure rate. Skin cancers can have microscopic roots, and it’s important that we get these roots out so that they don’t grow back. We perform a process called Mohs surgery, and we’re basically checking it as we go underneath a microscope. Under local numbing medicine, a skin cancer is cut out, we look at it underneath a microscope, if there’s still tumor present, we go back, and we take more. If it’s not, once the tumor is cleared and all the margins are negative then that area can be repaired and sewn back together.
Bill: It sounds like it’s highly targeted and you go and then you look again, go and look again, and then when it’s all gone, you stop basically?
Dr. Brady: Exactly.
Bill: So by preserving as much normal surrounding tissue as possible, I imagine you get a better cosmetic result then, too, right?
Dr. Brady: Right. Not only do you have a better cosmetic result, but you also get a better functional result as well. As you mentioned before, a lot of the locations that we’re doing the surgery are on the face, the head, the neck, hands, feet, genital areas, so you can imagine that the smaller we keep the defect size, the better function you’re going to preserve the surrounding areas. This is especially important if we’re working around the eyes, the nose, the ears, the mouth, so not only just the cosmetic result, or how it looks afterward, but also the functional result.
Bill: Right, functional, as well. Who is a candidate for this, Dr. Brady?
Dr. Brady: The main skin cancers that we tend to treat are basal cell cancers and squamous cell cancers. Those are the majority of skin cancers that we see, so when these skin cancers are located in the areas that I mentioned before – face, head, neck area, hands feet, genitals – that would be an indication for Mohs surgery. Also, tumors that have recurred, so those tumors that had been treated in the past and now they’ve come back, any large, aggressive, or rapidly growing tumors, tumors where the edges aren’t clearly defined. That means it’s hard to tell where they start and stop with the naked eye so you would need the aid of a microscope. Also, patients who have suppressed immune systems, so we see a lot of organ transplant patients with suppressed immune systems that are at higher risk of developing skin cancers. All of these would be indications for Mohs surgery.
Bill: So there’s a wide variety of benefits and applications for Mohs surgery then? Now you mentioned it is performed as an outpatient procedure. Can you talk about that a little bit? Is this a short procedure? I know it depends on each individual patient, but can you give us a general idea of what that’s like?
Dr. Brady: We tell the patients to block off an entire day with us just because we’re not sure how long each individual procedure will take. Sometimes patients are here for a couple hours, however, if the skin cancer seems to be quite extensive when looking underneath the microscope, they could be here well into the afternoon. We basically tell them that they should at least plan to spend all day with us and not make plans for the rest of the day.
What happens is, usually the patients will come in in the morning and in general, Mohs surgery is done under local numbing medicine. That means that they can eat breakfast before they come, they can have snacks, they can have lunch throughout the day. Most of the time they’re able to take all their normal medications. We may instruct them to stop some, and that just depends on each individuals’ personal medical history. After they get numbed up, the tumor is removed, it’s cut out, and that only takes several minutes, and the patient’s then bandaged, and they have a seat in the waiting room. They can hang out with their family member or friend, or whoever came with them. They can read books, they can watch TV, they can use wifi, whatever keeps them occupied during that time because it usually takes maybe 45 minutes to an hour while the microscope slides are being processed and analyzed. If there is still tumor present, I will mark it on a map, and then I will go back, and I will take more where I need to. If the tumor is clear, then the area can be reconstructed again. If the tumor’s not clear, we have to repeat the process back-and-forth, and every time we check the tumor underneath the microscope, they’ve got another hour or so to wait. Most of the time when the tumor has been cleared, those areas will be repaired by the Mohs surgeon and most surgeons are thoroughly trained in reconstruction techniques. We do side-to-side closures. we do grafts, which means taking skin from one area of the body and using it as a patch over that hole. We do flaps, which means taking adjacent, looser skin, and sliding it into place. Other times, the defect itself is quite small; we can just let it heal in on its own. Once the patient’s reconstructed, once they’re repaired, then they get bandaged up, and then they're discharged for the day.
Bill: After discharge, what is the general recovery time?
Dr. Brady: It's going to depend on how large the tumor was that was removed, and also that area – the part of the body that it was removed from – but in general, I’d say most of my patients have some slight discomfort for two to three days, and that’s usually something that’s amenable to over the counter medications, like acetaminophen, Tylenol. We tell them that for the next one to two weeks – again, depending on where they had the surgery – they shouldn’t do any bending, heavy lifting, exercising, going to the gym. Like any surgical procedure, they’re going to have some redness. They’re going to have some puffiness and swelling. They’re going to have some bruising. All of this is going to resolve over time. I do tell my patients as far as long-term expectations that you can’t cut the skin without leaving a scar. Initially, the surgical site is going to be noticeable, but I tell them also, my goal is at one year if a stranger were to approach them on the street, that stranger should not be able to tell that they had surgery performed.
Bill: Well, that’s very good news, and that’s what everybody wants to hear. Are there any possible risks involved with Mohs surgery?
Dr. Brady: The risks that are involved tend to be bleeding and infection, which is still pretty low. It’s about 2%, but those are the main risks. There’s a small chance that the tumor could recur – Mohs surgery does have a high cure rate, up to 99% for basal cells and squamous cells, but there’s still about that 1% chance that it still could come back. Other risks are because we are cutting through the skin and attempting to remove tumor, it’s going to depend on how wide and how deep that tumor goes that we could be getting into other structures, so maybe nerves, they may be left with some residual numbness. Rarely, they can have some defect as far as movement of the face, but again, it’s going to depend on how deep and how wide we have to go to get that skin cancer out. Most of the time the nerve damage is restricted just to numbness and rarely does it involve any motor function.
Bill: And Dr. Brady, you’ve talked about the cure rate for Mohs surgery. This sounds like it’s highly effective. Can you just spend a little bit of time on that? What’s the percentage again of efficacy on Mohs surgery?
Dr. Brady: Up to 99% for basal cells and squamous cells, and that’s because we’re looking at the entire margin around the area that we remove. We look at 100% of the side margins and 100% of the deep margin, meaning the margin that’s underneath the tumor that we remove.
Bill: So generally, if you have Mohs surgery done, there’s a pretty good chance it’s not coming back again?
Dr. Brady: That’s true, yes. It’s more likely that a patient would develop a skin cancer somewhere else. Once a patient has been diagnosed with a skin cancer, they’re at a higher likelihood of developing a skin cancer elsewhere just because they probably have the risk factors that have set them up for it, sun exposure over the years, fair skin, light eyes, blonde or red hair, a lot of moles. Now they have a personal history of skin cancer, they’ve had a family history of skin cancer, so it’s more likely that they would develop a skin cancer unrelated to the first one, but just related in the fact that they’re a setup to developing skin cancers, so we do recommend that they continue regular, routine skin checks with a dermatologist, just to make sure that nothing’s coming back, they’re not growing anything new, and if they are that the Dermatologist can catch it early.
Bill: Dr. Brady, thank you so much. That’s great information. Thank you for explaining Mohs surgery to us. For more information, visit RoswellPark.org, that’s RoswellPark.org. You’re listening to Roswell Cancer Talk. I’m Bill Klaproth, thanks for listening.