What is a board certified Mohs surgeon?
A board certified Mohs Dermatologic Surgeon is a dermatologist who has done extra fellowship training in Mohs Micrographic Surgery and passed a rigorous board exam. 2021 was the first year this board exam was offered and Dr. Melissa Babcock was one of the first Mohs surgeons in the country to become a board certified Mohs surgeon. Many physicians perform Mohs surgery in Atlanta without completing the extra fellowship training in detecting complex tumors under the microscope and the plastic surgery techniques to fix the skin after the surgery. If your doctor has referred you to a Mohs surgeon for your skin cancer, make sure the Mohs surgeon has done the proper fellowship training and is board certified not just in dermatology but board certified in Mohs Dermatologic Surgery.
How do I prepare for my day of surgery?
On the day of surgery expect to be in the office for 3-4 hours. Please bring a book, headphones or your favorite electronic device to help you pass the time. You can have a friend or family member come with you but it is not necessary. Most patient are able to drive themselves home after surgery.
Please do not wear make-up, moisturizer or sunscreen if the skin cancer is on your face and do not use hair care products if the cancer is on your scalp. Please do not wear perfume. Ideally take a shower the night before or the morning of surgery.
Have a good breakfast before surgery. No need to fast for this in-office procedure. You can bring food and water to your appointment if you wish.
Do not take aspirin, ibuprofen (Motrin), naproxen (Aleve), fish oil or other blood thinners before surgery. Ideally stop blood thinners and vitamins 2 weeks before surgery. Please don’t stop any blood thinners without checking with your primary physician if you are taking them for medical conditions. You can take acetaminophen (Tylenol) before and after surgery as it is not a blood thinner.
Purchase non-stick gauze bandages and paper tape from the drug store for after the surgery. Please have new Vaseline or Aquaphor at home for after surgery. Antibiotic ointments are usually not needed. Have Tylenol at home for pain control after surgery.
What is Mohs Surgery?
Mohs surgery is the most advanced technique in removing skin cancer. It is a technique that delivers the highest cure rate with the smallest amount of normal tissue removed. Therefore, the resultant scars are smaller and the recurrence rate less than traditional treatments.
In the early 1940’s Dr. Frederick Mohs, Professor of Surgery at the University of Wisconsin, developed a form of treatment for skin cancers he called chemosurgery. He combined the art of surgical excision with pathologic evaluation. The tumor and its “roots” can be tracked in one procedure. This is what gives it such a high cure rate. It is performed by a team of medical personnel which includes physicians, nurses and technicians.
Dr. Babcock, heading the team, has had subspecialty training in Dermatologic Surgery and is recognized by the American College of Mohs Microscopic Surgery as a result of this extra training. She is highly skilled at locating and removing skin cancers using the Mohs technique. Additionally, she was trained in the facial reconstruction techniques for fixing the skin after the removal of cancer. The nurse is an important part of the team who will help answer questions, assist in surgery, and instruct you in dressing and wound care after the surgery is performed. A histotechnician performs the essential task of preparing the tissue slide, which are examined under a microscope by Dr. Babcock during the procedure.
The surgery is performed as follows: the skin suspicious for cancer is treated with a local anesthetic so there is no feeling of pain in the area. A thin piece of tissue is then removed surgically around the biopsy site. The edges are marked with colored dyes. Next a careful diagram is made of the excised tissue and then glass slides are made by the technician. Dr. Babcock will then examine the slides under the microscope and determine if tumor is still present. If cancer cells remain, Dr. Babcock is able to exactly locate them based upon the diagram. Another layer of tissue is then removed from the area identified and the procedure is repeated until no cancer cells are seen. Since Mohs surgery, the cancer is “tracked”, the cure rate is highest while preserving as much normal healthy surrounding skin as possible.
The removal of each layer of tissue takes approximately one hours. Only 10-20 minutes of that is spent in the actual surgical procedure, the remaining time being required for the slide preparation and interpretation. It usually takes removal of two to three layers of tissue (called “stages’) to complete the surgery. Therefore, Mohs surgery is generally finished in one day. Sometimes, however, a tumor may be extensive enough to necessitate continuing surgery a second day.
What happens after the skin cancer is removed?
At the end of Mohs surgery, you will be left with a surgical wound. This wound will be dealt with in one of several ways. The several options will be discussed with you in order to provide the best possible functional and cosmetic results. You will have a scar after the cancer is removed. No physician can surgically remove skin cancer and not leave a scar. Dr. Babcock carefully examines you after Mohs surgery to determine which method will leave you with the smallest, least noticeable scar.
The possibilities explained below include: 1. Healing by granulation (“second intention”); 2. Closing the wound, or part of the wound with stitches; 3. Using a skin graft; 4. Using a skin flap; or 5. Arranging a consultation with a surgeon who specializes in more complicated surgical repairs.
Healing by granulation involves letting the wound heal by itself. This offers a good chance to observe the wound as it heals after removal of a difficult tumor. Experience has taught us that there are certain areas of the body where nature will heal a wound nicely as any further surgical procedure. Healing time is 6-8 weeks
Closing the wound with stitches is the most common way to fix wound. This involves some adjustment of the wound and sewing the skin edges together. This procedure speeds healing and can offer a good cosmetic result. For example, the scar can be hidden in a natural skin line.
Skin grafts involve covering a surgical site with skin from another area of the body. The skin is usually removed from behind the ear or around the collarbone (the donor site), and stitched to cover the wound. The donor site is then sutured together to provide a good cosmetic result.
Skin flaps involve movement of adjacent, healthy tissue to cover a surgical site. Where practical, they are chosen because of the excellent cosmetic match of nearby skin.
If your Mohs surgery is extensive or is performed where a functional impairment results, we may recommend you visit one of several consultant physicians. If you have been sent to us by a physician skilled in skin closures (for example, a plastic surgeon), he or she will usually take care of you after your cancer has been removed.
How successful is the treatment of skin cancer?
Mohs surgery has the highest cure rate of any method reaching a 98-99% cure rate. Other treatments have a success rate greater than 90%, depending on the tumor type, size and location. Methods commonly used to treat skin cancer include excision (surgical removal and stitching), curettage and electrodesiccation (scrapping and burning with an electric needle), cryosurgery (freezing), and radiation therapy (“deep X-ray”). The method chosen depends upon the microscopic type of tumor, the location and size of the cancer, and previous therapy.
The success rate in treating a recurrent (previously treated) skin cancer by conventional means is often as low as 50%. The success rate for Mohs surgery in treating recurrent lesions, is about 95-98%. So why isn’t Mohs surgery used to treat all skin cancers? The answer is time and money. Mohs surgery takes longer to perform and is more expensive. Mohs surgery is reserved for recurrent skin cancers or for primary skin cancers that have lower cure rates when treated initially with other therapies, such as those on the head and neck.
What can I expect after the surgery is complete?
Will I have pain?
Most people are concerned about pain. Usually patients experience little discomfort after surgery. Due to its potential to cause bleeding, we request that you do not take aspirin, or NSAIDs (ibuprofen, Aleve). You can use Tylenol. A stronger pain reliever can be prescribed if you are experiencing excessive pain. Please call the office with your pharmacy phone number and the medication will be called in for you.
Will I have bleeding?
A small number of patients will experience some bleeding post-operatively. This bleeding can usually be controlled by the use of pressure. You should take a gauze pad and apply constant pressure over the bleeding point for 20 minutes; do not lift up or “peek” during that period for 20 minutes. (If you lift the gauze pad before the 20 minutes are complete you will have to start the process again.) If this fails, call Dr. Babcock or visit a local Emergency Room. It is advisable not to drink alcohol the first post-operative night, as this may stimulate bleeding. We also ask patients to not do exercise for 7 days after the surgery to reduce the risk of bleeding.
Can there be complications?
There are some minor complications that may occur after Mohs surgery. A small red area may develop surrounding your wound. This is normal and does not necessarily indicate infection. However, if this redness persists or worsens in two days or the wound begins to drain pus, you should notify Dr. Babcock immediately. Itching and redness around the wound, especially in areas where adhesive tape has been applied, are common and not an infection. If this occurs, apply over-the-counter hydrocortisone and call our office. Swelling and bruising are very common following Mohs surgery, particularly when it is performed around the eyes. It is common for one or both eyes to swell shut 1-3 days after surgery. This usually subsides within four to five days after surgery and may be decreased by the use of an ice pack in the first 48 hours. At times, the area surrounding your operative site will be numb to the touch. This area of anesthesia (numbness) may persist for several months or longer. In some instances, it may be permanent.
Although every effort will be made to offer the best possible cosmetic result, you will be left with a scar. The scar can be minimized by the proper care for your wound. We will discuss wound care in detail with you and give you Wound Care Information Sheets that will explicitly outline how to take care of whatever type of wound you have.
Will there be restrictions?
We ask that you avoid exercise for one week after the surgery. Strict avoidance for the first 48 hours is important to avoid bleeding and sutures opening. During the first 7 days you can walk but no running, golf, tennis, yoga, weight lifting, elliptical, etc. Any activity that can raise your blood pressure can lead to bleeding. Additionally, activity in the first week after surgery can lead to more scarring.
We ask that you keep the surgical area dry for 24 to 48 hours after surgery. Please shower or bathe the night before or morning of the surgery. Also shaving away any hair the night before the surgery can be helpful.
We are excited to offer various treatments to help your wellbeing and look of your skin. While we strive to provide the latest content on Babcocok Dermatology’s website, is not to be taken as medical advice. Babcock Dermatology is not responsible for any omissions of information or any damages arising from the content on our website. For any treatment it is important for you to understand that results and individual experience may vary. For many dermatologic treatments common side effects include numbness, discomfort, bruising, and swelling. Rare side effects can occur. Before your cosmetic treatment we provide an informed consent which is a document with the common side effects and cost of the procedure written out. We also encourage patients to ask any questions before a treatment.