Skin Cancer: What Is Mohs Surgery?

Reprinted from a tweet from HealthAfter50

Published: December 15, 2016

Medically reviewed by Timothy Wang, MD

If you basked in the sun when you were younger, you may be paying the price for that exposure as you grow older. Research reports that one in five Americans will eventually develop skin cancer.

Most people are likely to develop basal cell or squamous cell carcinomas. Both are often grouped as nonmelanoma skin cancers. This distinguishes them from the most dangerous type of skin cancer, melanoma.

Nonmelanoma skin cancers carry a lower risk of metastasizing (spreading to distant parts of the body) than melanoma. Though slow growing and rarely life-threatening, nonmelanoma skin cancers can cause disfigurement and metastasize if left untreated.

Nonmelanoma skin cancers often begin as a small bump or tender area that may bleed and/or scale or crust. Although skin cancers can develop anywhere, most occur in sun-exposed areas such as the face.

According to an analysis published in the April 2012 Archives of Dermatology, a growing number of Medicare patients are undergoing surgery to treat nonmelanoma skin cancers, which are typically associated with accumulated exposure to ultraviolet rays from the sun.

Nonmelanoma skin cancers can be treated in a variety of ways. Your doctor will choose the best option based on your tumor’s size, location, and growth pattern. Standard forms of treatment include:

• Conventional excisional surgery
• Scraping & burning
• Radiation therapy
• Cryotherapy (freezing & destroying)
• Topical medication such as imiquimod

Another procedure, called Mohs micrographic surgery, is being used more and more, particularly to treat skin cancers on the face.

Mohs surgery has a high cure rate and preserves more healthy, noncancer-containing tissue. It can leave a smaller defect and, subsequently, a smaller scar.

How Mohs works

Mohs surgery is named after Frederic E. Mohs, M.D., the surgeon who developed the original technique in the 1930s. It is used predominantly to treat facial lesions, especially those on the lips and eyelids, where tissue preservation is critical. Mohs also has a high cure rate in treating recurring nonmelanoma skin cancers.

Not everyone is a candidate for Mohs surgery. Having other health conditions may preclude some people from undergoing the procedure, especially patients ages 85 and older. Also, undergoing the faster excision surgery instead of the lengthy Mohs procedure may be more practical for elderly patients.

The Mohs technique is a specialized outpatient procedure using local anesthesia performed by a doctor who has been trained to act as both surgeon and pathologist (an expert in analyzing tissue). Mohs also requires a specialized technician and laboratory to process the tissue.

You are awake during the surgery, and the surgical site is locally anesthetized. The Mohs surgeon removes your tumor in layers and examines each layer under a microscope to look for remaining evidence of cancer. (The lab work takes about an hour.)

If the surgeon finds any portion of the tumor remaining, he or she removes additional layers, repeating the process until the cancer is absent. The entire procedure typically lasts two to four hours and sometimes longer depending on the extent of cancer. The surgeon typically removes one to four layers.

Once the cancer has been completely removed, the defect can be reconstructed, often on the same day.

Wound reconstruction

After the cancer is removed, your Mohs surgeon can choose from a number of options when deciding how to repair the defect. They range from simple—the defect is allowed to heal on its own over the following weeks—to very complicated—a series of surgical procedures are performed.

Many Mohs surgeons are specially trained to perform both Mohs excision and repair. Sometimes, however, depending on the defect’s size and location, other specialists may be called on to complete reconstruction.

Your doctor may give you pain relievers to ease any discomfort from the surgery and/or oral antibiotics to prevent infection immediately after the procedure. Mohs surgical complications are rare but can include excessive bleeding, nerve damage, infection, wound reopening, and formation of a keloid (a tough, raised scar) at the surgical site.

Post-Mohs

As with any type of surgery, Mohs leaves some degree of scarring. As your wound heals, you can expect to see firm scar tissue and some discoloration. All scars soften and improve with time, but it may take months to a year or more for the scar to heal completely.

Some patients may need additional procedures such as sanding, laser treatment, or injections for the scar to look its best. Be sure to talk with your doctor before your surgery about your expectations, including wound-healing, scarring, and post-operative care issues.

You’ll need to visit your doctor for regular checkups. Once you’ve had skin cancer, you’re at a higher risk for developing it again.

In fact, 40 percent of patients who’ve had a basal cell carcinoma develop another one within five years, so it's important to watch for new lesions and visit your doctor regularly.

And of course, adopt safe sun practices, such as wearing lip balm and sunscreen with a sun protection factor (SPF) of at least 30.

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My note: When dealing with any medical issues--don't be afraid to have a conversation with your doctor and discuss your concerns and ask questions. 

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Should You Be Screened for Melanoma?

Should You Be Screened for Melanoma?

New skin-cancer-screening recommendations 

might have you confused

Consumer Reports / Julia Calderone  / July 26, 2016 / www.consumerreports.org

You might think that with all the concerns about melanoma, the benefits of having your skin checked every year by a doctor for skin cancer would be clear. But it isn't.

The U.S. Preventive Services Task Force, an independent group that advises the government on public health issues, just released its latest analysis on skin cancer research.

After analyzing the abstracts and text of about 13,000 studies going back 20 years, they narrowed it down to 13 to include in the review. Their conclusion: There's not enough evidence to say that regular professional skin checks save lives, or to recommend for, or against, routine checks. That's the same conclusion the Task Force reached back in 2009, the last time it did a comprehensive review of the research.

Does that mean that you skip the exams? No. David C. Grossman, M.D., the vice chair of the Task Force and a senior investigator at the Group Health Research Institute Group Health in Seattle, says that in the absence of clear benefits (or harms), the decision depends largely on you and your doctor's assessments of your personal risk.

Our medical experts agree, and stress that the Task Force's review didn't look at people at high risk, or assess the benefits of seeing a dermatologist instead of a primary care provider. It also did not evaluate the effectiveness of self-examinations.

"The greater your risk of skin cancer, the more important regular skin checks, preferably by a dermatologist, becomes," says Jessica Krant, M.D., a clinical assistant professor of dermatology at SUNY Downstate Medical Center in Brooklyn, N.Y., and a member of Consumer Reports’ medical advisory board.

In addition, the Task Force's inconclusive take on professional skin cancer screenings underscores the importance of you taking an active role in preventing the cancer and catching it early. That means taking steps to avoid the UV radiation that can cause skin cancer, and also periodically checking your own skin, so you notice when worrisome changes appear.

Here why skin cancer is such a concern, and what you should consider as you determine when and how often you should have your skin checked.

Know Your Risks

The number of people developing and dying from melanoma has risen steadily for the last 30 years, according to the American Cancer Society. About 10,000 Americans each year now die of the disease, and some 76,000 are diagnosed with it. More than 5 million other people develop basal and squamous cell cancers, two of the more common but less deadly types of skin cancer.

Melanoma can appear suddenly and spread quickly, making it important to catch it early.

For that reason, our medical experts say it is important that you be aware of changes on your skin, and to contact your doctor if you see any worrisome shifts. A 2009 study in the journal Archives of Dermatology found that 44 percent of melanomas were discovered by patients. Look especially for skin lesions that are asymmetrical, have irregular or ragged borders, are multicolored, are larger than a pencil eraser in diameter, or are changing over time. Find out how to spot melanoma.

In addition, you should get a skin check, at least every year if you are at high risk of skin cancer, Krant says. Preferably, that doctor should be a dermatologist. Their advanced training makes them better able to identify worrisome lesions, which means that they are less likely to overlook dangerous melanomas and refer you to needless biopsies.

Factors that increase your risk of skin cancer include:
• a history of sunburns;
• fair skin, light eyes, or red or blond hair;
• a family history of melanoma; and
• a personal history of basal cell or squamous cell cancer.  

Even if you are at lower risk you should still periodically have your skin checked by a physician; consider asking for a referral to a dermatologist for the exam.

Prevention is Key

Not all skin cancers can be prevented by avoiding UV rays. Genetics play a strong role in the cancer, and you can develop the malignancy even on parts of the body that rarely see the sun.

Still, taking steps to avoid radiation can cut your risk of developing the disease. One simple step: Avoidindoor tanning. Experts estimate that it causes a 450,000 new skin cancer cases each year, of which 10,000 are melanomas.

It also pays to limit your exposure to the sun’s damaging rays. Spending less time directly in the sun, especially between 12 noon and 3 p.m. is one of the most important things you can do, Grossman says.

And when you are out in the sun, wear a broad-rimmed hat and protective clothing when you can, and use sunscreen all the time. Here's how to make sure you apply sunscreen correctly.

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