Mohs Surgery Unit
If you have recently been diagnosed with skin cancer, you are not alone. Over one million people are diagnosed with skin cancer in the U.S. each year, making it the most common type of cancer. Fortunately, it is also one of the most treatable forms of cancer.
Some skin cancers are readily treated with topical creams, cryotherapy (freezing), electrodesiccation and curettage (burning and scraping), or simple excision.
- located on cosmetically or functionally critical areas (especially on the face)
- recurrent after failing previous treatment
- clinically ill-defined or infiltrating
- aggressive, large, or rapidly growing
Mohs surgery was developed by Dr. Frederic Mohs in the 1930’s. During this procedure, the visible skin cancer is removed and processed in the Mohs laboratory, examining all of the edges of the specimen under a microscope. If any skin cancer remains, the area of remaining cancer is re-excised and, again, examined under a microscope. This process is repeated until the entire skin cancer, including any roots, is completely removed (see diagram). Once the tumor has been proven to be completely removed, most wounds are then repaired and sutured.
The Mohs technique offers several advantages over other treatments:
- provides the highest cure rate of any treatments for skin cancer-up to 99 percent
- minimizes the removal of normal skin tissue allowing for potentially smaller scars
- performed under local anesthesia as an office based procedure
Skin cancers often extend beyond their visible borders. It is these extensions that cause the tumors to recur if not completely removed.
Like other surgical procedures, Mohs surgery first removes the visible tumor.
A thin layer of normal tissue is removed, mapped and evaluated by the surgeon with a microscope.
Additional layers may then be taken precisely in the areas of remaining cancer until the tumor is completely removed.
Mohs surgery is the only method that ensures all of the tumor is removed while preserving the maximum amount of healthy tissue and therefore minimizing scars and cancer recurrence.
Frequently Asked Questions
Who are candidates for Mohs surgery?
Mohs surgery should be considered in basal cell and squamous cell carcinoma at risk for recurrence. These factors are well known and are based on past history, type of basal cell carcinoma and location. Recurrent tumors, tumors in the “T” or “H” zone (midface and ears), large tumors (greater than 2 cm) are all candidates for Mohs surgery. In addition, certain basal cell carcinomas such as morpheaform, infiltrating, micronodal, adenoid and multifocal tumors are more likely to recur and thus are candidates for Mohs surgery. Squamous cell carcinomas can also be addressed well. With Mohs surgery some rare tumors such as dermatofibrosarcoma protuberans, microcystic adenexal carcinoma are successfully treated with Mohs surgery. We also use a modified Mohs surgery on early melanoma in selected cases.
As you can see, the decision for Mohs surgery verses alternative therapies is complex. Your skin specialist can assist you in the evaluation of your lesion, including biopsy, and help you decide if Mohs is appropriate for you.
Tell me about the Mohs surgery unit at Brown Dermatology.
The Mohs Surgery Unit at Brown Dermatology, Inc. has treated over 15,000 cases of skin cancers in Rhode Island with Mohs surgery. The Mohs surgery unit is more than 2,000 square feet and includes five surgery suites, an integral lab, and a dedicated patient waiting area for privacy. The lab is Clinical Laboratory Improvement Amendments (CLIA) inspected and approved by the federal government.
If Mohs surgery has the best cure rate for nonmelanoma skin cancer, why aren’t all skin cancers removed with Mohs surgery?
There are multiple treatments available for skin cancers, including electrodessication and curettage (burning and scraping), laser, excision, radiation, interferon and topical 5-fluorouracil. Your skin specialist can assist you in the selection of the optimum treatment. Each situation is different, but with proper selection, cure rates of 90-93 percent with the above techniques are expected. The key is proper selection.
What are the benefits of Mohs surgery?
Mohs surgery offers the highest cure rate for nonmelanoma skin cancers, usually greater than 95 percent. This is due to the more careful evaluation of the tissues. Additionally, less healthy tissue is removed during Mohs surgery than during a routine excision. This offers an added advantage for removing tissue in delicate areas of the nose, eyelid, ears and lips. In addition, Mohs surgery is offered in an office setting with local anesthesia for added safety and cost effectiveness.
What should I expect the day of my surgery?
You should eat your regular breakfast and take all of your medications as usual on the day of surgery unless specifically told otherwise. A nurse completes a preoperative evaluation. The doctors will clean the surgical field with an antiseptic and inject you with local numbing medicine. You will not be put to sleep; however, please have someone drive you home.
Once the surgical area is numb, the skin cancer will be cut out, sent to the lab and made into microscope slides. The process may take 30-45 minutes. If there is some cancer left based on the microscopic exam, the process of removing tissue is repeated until the entire tumor has been completely removed based on microscopic examination.
While most patients have their skin cancers removed in two or three “rounds” of surgery, it is impossible to know exactly how many rounds it will take for your skin cancer. Expect to be here for half of a day. Similarly, it is impossible to know exactly how large your wound will be until the surgery is completed.
Once the skin cancer has been removed, the wound is repaired. The repair may be performed by suturing the wound directly, rearranging skin from adjacent areas (flap), grafting skin removed from another site, or allowing it to heal by itself without suturing. The wound size and location determine the type of repair performed.
Common risks of the procedure include pain, bleeding, infection, scarring, numbness and nerve damage, and the risk of recurrence. Ice and Tylenol are the first step for pain control after surgery. The risks of bleeding and infection are approximately one to two percent, but can be minimized with careful post-operative care. While Mohs surgery guarantees the highest cure rates, no technique offers a 100 percent chance of a cure. There is a small chance, at least one to two percent, depending on tumor type and location, that the skin cancer will recur.
Anytime the skin is cut, a scar will develop. All steps are taken to minimize the cosmetic and functional significance of any scars. It is important to remember that complete healing of the scar takes place over 6-12 months. The surgery site may feel swollen, “lumpy”, and there may be redness for the first few months after surgery. This is part of the normal healing process.
What should I expect on the day of my consultation?
The Mohs surgery team will complete a consultation during which we will ask that you complete a brief form about your past medical history. The consultation is to ensure you understand why you have been referred for the procedure, what options you have for treatment and what to expect the day of your surgery. The consultation also helps the doctors determine if you are medically prepared for the procedure. After this consultation, you will be scheduled for surgery.
Our Mohs Surgeons
Victor A Neel, M.D., Ph.D.
Director, Division of Dermatologic Surgery
Dr. Neel is the Director of Brown Dermatologic Surgery Unit. He graduated from Princeton University; received his M.D. from Cornell University Medical College; and his Ph.D. in genetics from Rockefeller University. He completed his dermatology residency at Brown University School of Medicine. Afterwards, he became a fellow in Mohs Micrographic Surgery and Cosmetic Dermatology at the UCLA School of Medicine.
Professionally, Dr. Neel is a member of several professional associations including American College of Mohs Surgery (ACMS) and the American Society for Dermatologic Surgery (ASDS), where he is a preceptor (teacher) for several procedures. Dr. Neel is also Assistant Professor of Dermatology at Harvard Medical School. He is a co-author of numerous peer-reviewed and non-peer reviewed publications in print, online media, and other media regarding issues such as skin cancers and Mohs surgery, as well as minimally invasive procedures to help aging skin. He has a particular interest in the biology of skin cancer and the genetics of aging, and has several ongoing clinical studies and basic research projects.
H. William Higgins, M.D., M.Be.
Assistant Professor of Dermatology
Dr. Higgins graduated from Connecticut College, and received his medical degree from Florida State University College of Medicine where he graduated at the top of his class as a member of the Alpha Omega Alpha national medical honor society. He then completed internship in internal medicine at Yale University, dermatology residency at Brown University, and Mohs micrographic surgery fellowship at Yale University. While at Brown, he served as Chief Resident and was awarded the prestigious Haffenreffer Housestaff Excellence Award. He also served on the faculty of Yale School of Medicine, Department of Dermatology, as a clinical instructor.
Dr. Higgins is Board Certified by the American Board of Dermatology and is a member of the American Academy of Dermatology, American Society for Dermatologic Surgery, American College of Mohs Surgery, and the American Society for Lasers in Medicine and Surgery. He currently practices Mohs microscopically controlled surgery, laser and cosmetic dermatology. He served as the Resident Representative to the Board of Directors of the American Society for Dermatologic Surgery, and has been appointed to numerous leadership positions, including the American Academy of Dermatology’s Leadership Development Forum.
His interests include cutaneous oncology, complex surgical management of skin cancers, and melanoma. He has authored over 30 peer-reviewed articles and book chapters. Dr. Higgins has also presented at numerous national meetings on skin cancer epidemiology.