Rhett Drugge, M.D. | Cosmetic Procedures | Mohs Micrographic Surgery

Mohs Micrographic Surgery is a specialized procedure for the removal of skin cancer. The procedure is named after the originator of the technique, Dr. Frederick Mohs. This information packet was written to help you understand what Mohs Micrographic Surgery is, and why it is recommended for the treatment of skin cancer.

Rhett Drugge, M.D., is board certified as a dermatologist by the American Board of Dermatology and Dermatologic Surgery and is a fellow of the American Society for Mohs Surgery.

Dr. Drugge is one of a very small number of specially trained dermatologists who performs Mohs Micrographic Surgery in this region. This highly successful surgery is offered in an outpatient setting at the dermatology office of Dr. Charles Sheard and Dr. Rhett Drugge on 50 Glenbrook Road in Stamford, Connecticut. Patients who undergo Mohs Micrographic Surgery do so in relative comfort and do not require a hospital visit.

Dr. Drugge encourages patients to be as informed as possible about the surgical procedure they are considering. He and his staff are available to answer any questions you might have.

Skin cancer, by far the most common malignant tumor in humans, is an abnormal growth of cells that expands in an unpredictable pattern on the skin. The most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and malignant melanoma- each named for the particular skin cell from which it arises. Basal cell carcinomas and squamous cell carcinomas are commonly treated by Mohs Micrographic Surgery in our office. Other types of skin cancer can also be treated with Mohs Micrographic Surgery.

Both basal cell carcinoma and squamous cell carcinoma begin as a single point in the upper layers of the skin and slowly enlarge, spreading both along the surface and downward. These extensions cannot always be directly seen. The tumor often extends far beneath the surface of the skin. If not completely removed, both types of skin cancer may invade and destroy structures in their path.

Although these skin cancers are locally destructive, they do not metastasize (spread) to distant parts of the body. Metastasis is extremely rare in basal cell carcinoma and usually occurs only with long-standing, large tumors. Squamous cell carcinoma is slightly more dangerous and patients must be observed for any spread of the tumor, although it is unlikely. Certain types of melanoma are treated by Mohs Micrographic Surgery in our facility.

Excessive exposure to sunlight is the single most important factor associated with the development of skin cancers. In addition, the tendency to develop these cancers appears hereditary in certain ethnic groups, especially those with fair complexions and poor tanning abilities. Fair-skinned people develop skin cancers more frequently than dark-skinned people and the more sun exposure they receive, the more likely they are to develop a skin cancer. Other factors, including exposure to certain chemicals, may also be involved in the development of skin cancers. But the highest incidence of skin cancer is found in cities such as Dallas and Miami where the sun is very intense.

There are several methods for treating skin cancers, including excision (surgical removal), curettage and electrodesiccation (scraping and burning), X-ray therapy, cryosurgery (freezing), topical chemotherapy and Mohs Micrographic Surgery. The method chosen depends on the location of the cancer, its size, type, and previous treatment. Your doctor will base his recommendations on these factors.

Approximately 40 years ago, Dr. Frederick Mohs of Madison, Wisconsin developed a unique treatment of skin cancer called chemosurgery. Dr. Mohs applied a caustic chemical to "fix" (harden) the area involving the area involving the tumor, so that it could be removed and traced to all of its edges. Since then, the procedure has been refined. Today, almost all cases are treated by the "fresh tissue" technique which omits the use of this caustic chemical and allows dermatologists to remove all of the tumor layers in one day. Mohs Micrographic Surgery is a technique that enables dermatologists to selectively remove areas involved with the skin cancer, while at the same time preserving the greatest amount of normal tissue as is possible. If surgical repair of the defect is necessary, it can be done with the knowledge that there is no residual tumor left. As a result, Mohs Micrographic Surgery is very, very useful for large tumors, tumors with indistinct borders, tumors near vital functional or cosmetic structures and tumors for which other forms of therapy have failed.

Your first visit allows the doctor an opportunity to examine your skin cancer, obtain your medical history and determine whether the technique of Mohs Micrographic Surgery is the most appropriate treatment. It also gives you a chance to meet Dr. Drugge and his staff and learn about the procedure. If you have been referred to the office, we will usually have received a pathology report stating the type of skin cancer you have. If this information has not been obtained, we will perform a biopsy during your preoperative visit. This biopsy is important because it will tell us what type of cancer you have - a critical factor in planning your treatment. The date and time of your surgery will also be scheduled at this consultation.

Eat your usual breakfast. If you normally skip breakfast, please have a morning snack on the day of surgery.

Take all of your regular medications unless directed otherwise by your surgeon or your regular physician. If you take any medicine containing aspirin, salicylates, other pain medicine, anti-inflammatory medicine or arthritis medicine, please discuss this with Dr. Drugge.

Wear comfortable, loose-fitting clothing that you can easily get into and out of. Avoid any pull-over clothing. If necessary, we may give you a hospital gown to wear during your surgery. You may also want to bring a sweater in case the clinic room is air-conditioned.

Please leave your whole day available for surgery. That will allow enough time for you to rest and recover from the procedure. On the day of your surgery, we encourage you to bring a close friend or relative with you who can help you drive home and keep you company between each stage of the procedure.

If you are very anxious or nervous, we can give you a mild sedative prior to surgery. This must be arranged prior to the day of surgery. If you take a sedative, you must be accompanied by a close friend or relative who can take you home after your surgery.

Mohs Micrographic Surgery is performed in a procedure room under sterile conditions, with local anesthesia. Once anesthesia is complete, the visible portion of the tumor is removed by excision or scraping with a sharp instrument called a curette. Following the removal of most of the tumor, a thin layer, encompassing the complete undersurface of the tumor, is excised. That layer is then cut into small pieces and a map is drawn to identify the location of each piece. The edges of each piece are marked with dyes to aid in orientation on our map. Each piece is then frozen and these slices cut, stained, and examined under the microscope. Any areas in which the tumor is found are marked on the map. Regions with remaining tumor tissue are then reexcised. This procedure is repeated until no more tumor is found and the cancer is entirely removed. After each layer of tissue is obtained, oozing or bleeding vessels are cauterized or ligated with a suture. A pressure dressing is applied. You may then rest in a specially equipped waiting area with your family member or friend.

It takes 30 minutes to remove each layer of tissue, and one or two hours to process and examine it. Most tumors require the removal of three layers. Extensive tumors may need more surgery and may require a second visit.

If you have a basal cell carcinoma, there is about a 99 percent chance that you will be cured. If you have a squamous cell skin cancer, you can be about 95 percent certain that you will be cured by Mohs Micrographic Surgery. However, follow-up visits to detect the rare recurrence are very important. After the initial postoperative period, you will return to your referring physician for routine skin care and tumor surveillance. The Mohs surgeon will see you about once each year for five years to rule out the possibility of recurrence.

Since it is not possible to know the exact size of each skin cancer until it has been completely removed, we cannot determine your post-surgical treatment entirely in advance, although we can tell you what to expect. Many wounds are superficial and can heal on their own with excellent cosmetic results. If a surgical wound requires surgical reconstruction, we will discuss it with you following the complete removal of the cancer. Appropriate recommendations and referrals will be made at that time.

You surgical wound will likely require special care during the week(s) following surgery. You will have some swelling and redness around the wound. This will gradually disappear over seven to ten days. In larger wounds, some drainage may occur and may have a foul odor for a few days. You should plan on wearing a dressing and avoid strenuous physical activity for one to two weeks.

You may experience a sensation of tightness across the area of surgery. Skin cancers frequently involve nerves, and months may pass before your skin sensation returns to normal. In some cases, numbness may be permanent. You may also experience itching after your wound has healed. Complete healing of the surgical scar takes place over 12 to 18 months. Especially during the first few months, the site may feel swollen or lumpy and there may be some redness. Gently massage the area (starting about one month after surgery) and keep the area lubricated with lotion to speed the healing process.

Bleeding is rare. If it occurs, have someone apply firm pressure to the site. If a bulky dressing has been placed on the wound, this should not be removed. Direct pressure should be applied to the padded wound for 15 minutes, timed by watching a clock. Do not discontinue pressure to see if the bleeding has stopped until 15 minutes have elapsed. If the bleeding continues, continue to press directly with an additional clean gauze pad over the bleeding site for another 15 minutes. If bleeding continues, call our office or go to your local emergency room.

Mild to moderate pain is normal for a day or two following surgery, but it generally responds well to oral pain medications such as Tylenol or Tylenol #3. Do not use aspirin or anti-arthritis pain medications such as Motrin or Advil (ibuprofen) because they can cause bleeding. If regular pain medications provide insufficient relief, or if the pain increases after 3 to 4 days, you should contact our office.

The human body healed itself naturally for thousands of years before the advent of modern medicine, and it has great recuperative ability. After the complete removal of the tumor, several options may be considered for managing the wound.

Letting the wound heal by itself offers a good chance to observe the healing process and decreases the chance of a recurrent cancer being invisible or hidden. If at any time during the course of healing, the scar is deemed to be unacceptable, a cosmetic surgical procedure can be performed. Allowing wounds to heal this way is relatively painless and offers excellent cosmetic results for many body locations.

This procedure often speeds healing and can offer good cosmetic results, especially when the scar can be hidden in a line of facial expression or wrinkling. Sutures generally remain in place for 5 to 7 days, and occasionally up to two weeks, depending on the location. Do not bathe the area for the first 72 hours. On the fourth day following surgery, you may shower, but you must avoid bathtubs and swimming pools for 5 to 7 days.

Closing the wound with skin grafts, flap repairs or other reconstructive procedures

Recommendations or referrals for these procedures will be made after complete removal of the tumor. We will make recommendations that best serve each patient's needs.

You can act as your own nurse and will be impressed at the excellent job you can do. To facilitate the healing of your wound, you must change the dressing daily. With proper care you will be surprised and please at how well and rapidly your wound heals. The following materials may be required, but should not be purchased before you receive your postoperative instructions.

Keeping the dressing fresh and clean will facilitate healing. Follow these steps:

We want you to be as comfortable, relaxed and informed about your Mohs Micrographic surgery as possible. Please contact us if you have any questions.