Mohs Surgery
Lot of patients ask us what is the difference between Mohs micrographic surgery and a regular excision for treatment of a skin cancer. The main difference is Mohs surgery (named after Dr. Frederik Mohs) is only indicated for certain skin cancers (mostly NON-melanoma skin cancers such as SCCs or BCCs) in cosmetically “sensitive” areas like the face, hands, pretibial skin, and the feet. Why? Because it minimizes the margins needed to remove skin cancer. Usually, the clinically indicated margins for removal of a Non-Melanoma Skin Cancer (NMSC) is about half a centimeter. You could imagine how large of a removal this could be if you already had a ½ centimeter skin cancer on your eyelid or nose, and then needed to take ½ centimeter off the entire diameter of the cancer – there goes most of your normal tissue in the area! The beauty of Mohs surgery is that it helps us to minimize the margins of normal tissue we take surrounding the skin cancer, give it to the outside laboratory we hired to come into the office for the day, and turn that piece of skin into a biopsy slide that we read immediately in the office same day to ensure we only go back and take more skin if it is actually positive for skin cancer, and locate the exact place on the skin that its positive and go only there to take more skin. It is truly a precise surgical technique, used to treat various types of skin cancer, though mostly NMSCs. During Mohs surgery, thin layers of cancer-containing skin are progressively removed and examined until only cancer-free tissue remains. Mohs has a success rate approaching 99%.
For more information on our Mohs Surgery PreOperative instruction or Post Operative instructions and what to expect, Please see here:
For more information on our Mohs Surgery Pre Operative Checklist:
Excisions
We perform excisions, or skin removals, on “abnormal” moles (ie “dysplastic nevi”) or skin cancers. Surgical excision is a typically 20-30 minute in office procedure that involves taking a margin of normal healthy tissue around the site of the abnormal biopsy site. When we biopsy moles that appear “suspicious” (usually because they fall into the ABCDEs of melanoma) we usually get the biopsy results back within 7-10 days from the lab and it tells us “normal, abnormal, or melanoma”. When they report a mole as “abnormal” they usually score HOW abnormal it is, by saying its “mildly” dysplastic, “moderately” dysplastic, or “severely” dysplastic. When they report a mole as moderate or severely dysplastic, we usually go back and take more in the form of a surgical excision to ensure the margins are clear of abnormal cells.
This usually involves 20-30 minutes in our office, deep stitches are placed (that usually take 3-6months to dissolve) and top stitches are places (which are generally removed within 5-10 days in our office). You will get a local anesthetic (NOT general anesthesia), and these procedures are usually painless and uneventful. We send the tissue we remove back to the laboratory to determine that the margins of the abnormal mole or skin cancer are “clear”.
Biopsy Site Aftercare Instructions
Electrodesiccation and Curettage
(also called EDC or ED&C) is a procedure used to remove skin cancer. Basal cell and squamous cell cancers are types of cancer in which abnormal skin cells grow out of control. Most cases of these types of cancer can be cured if they are found and removed early. If the cancer is not completely removed, it may come back.
A local anesthetic is injected, and then the top layers of skin with the abnormal tissue is scraped off with a special tool called a curette. The area is then heated with an electric current through a hot needle (electrosurgery) to help control bleeding and destroy any cancer cells that remain. This process is usually repeated for 2-3 rounds if the growth we are treating is cancerous. Your provider will scrape a little beyond the edge of the cancer to help remove all the cancer cells. The wound is then covered with ointment and a bandage. A scab will form over the area. The wound may take 3 to 6 weeks to heal, depending on the size of the area treated. Good wound care may help the scar fade with time.
Recovery time typically is minimal. It can take up to 4-6 weeks for your wound to heal completely; 2-3 months to completely heal on the lower extremities. You may take Tylenol for pain if needed and not otherwise contraindicated.
During normal healing of this type of wound you can expect to see a yellowish center with a red surrounding edge. This area will slowly decrease in size as your wound heals until it is completely healed over. The resulting scar will be round and either pink/red, white or purple (on the lower extremities).
Initially some oozing from the site is normal. The wound is healed when there is no longer a crust on the site or drainage on the bandage.
Cosmetic Mole Removal / Unwanted Skin Growth removal
A mole that is considered “benign” is one that may be cosmetically removed. We can remove benign (non-cancerous) moles or skin growths anywhere on the body that you don’t find aesthetically pleasing. Depending on the type of lesion, we can cauterize them or gently excise them using a surgical blade. The spot is then covered with a bandaid for 5-7 days to promote proper healing. This treatment is minor and doesn’t usually involve any ‘downtime’.
Removal of Cysts and Lipomas
Cysts are a common benign growth seen in dermatology. Treatment may or may not be recommended based on size, symptoms, and location. If inflamed, they may be treated with a steroid injection or oral antibiotics. Full removal of a cyst, however, warrants surgical excision. This is a minor out-patient procedure in which the area is numbed locally and the cyst is removed in its entirety. The removed lesion is always sent to the lab to confirm that it is indeed a benign cyst. Oftentimes, people can get recurrent cysts on their scalp, called Pilar Cysts, which are usually genetic. We commonly remove these in the office with a simple 20 minute surgical procedure. Pilar Cyst Removal:
When cysts are small and on the face, they are usually called “milia” cysts, and a quick extraction can be performed to remove them. This requires NO numbing, and in skilled hands, a simple lancet and comedone extractor usually does the trick!
Earlobe Repair
Earlobe repairs generally happen when you have had a piercing that gets stretched out by wearing heavy earrings, or by some other trauma to the earlobe. Repairing the earlobe is a simple, in-office procedure that involves local anesthesia, like going to the dentist, and incising out the damaged earlobe and sewing the two sides back together. This allows you to have a clean fine scar instead of a torn earlobe, to help support future weight of earrings once you are able to re-pierce them. Earlobe Repair is not covered by insurance.
If the earlobe is not completely torn through, or not severe enough to warrant an excision of the earlobe, oftentimes we can inject a filler into the ear lobule to support the weight of earring and prevent the “torn” look. See us in consultation to determine which route is best for you.
Melanoma Removal
Melanoma is a potentially serious type of skin cancer that can occur on ANY part of the body, not just on sun-exposed skin. It involves the abnormal growth of melanocytes, or pigment-producing cells, of the epidermis (top layer of skin).
The main risk factors for developing the most common type of melanoma (superficial spreading type, 75%) are: personal or family history of a melanoma, multiple moles (usually >50), history of a previous Basal Cell or Squamous Cell Carcinoma, a history of multiple (>5) abnormal moles in the past, or white/fair skin that burns easily.
The types of melanoma are in situ ( if the tumor is confined to the epidermis), invasive (if the tumor has spread to the deeper layer of skin, the dermis), or metastatic (if the tumor has spread to other parts of the body). When melanomas are “in situ” or superficial, we remove them with a simple in-office procedure, a surgical excision, with appropriate margins. When we catch a melanoma that is beyond stage 0 in situ, we work closely with our colleagues at the Hoag Melanoma Center.
What to avoid before & after your treatment?
- Stop the use of all blood thinners including: fish oil, vitamin E, Aspirin, Motrin, Ibuprofen, Alcohol for 5-7 days prior to your treatment.
- Staying out of the sun when the UV rays are at their peak (12-2pm) for 2 days after your filler.Do not wear makeup on the day of treatment
- No facials or massages for 48-72 hours post treatment.
- No laser treatments for 2 weeks post treatment.
- Some medications or supplements may increase the risk of bruising. Consult with your physician.
- Notify clinic with any changes to your health history or medications since your last appointment
- History of herpes or cold sores may require an antiviral prescription prior to treatment
