Mohs Surgery

Mohs micrographic surgery is the gold standard for skin cancer treatment, offering the highest cure rates available today. During this precise procedure, your physician acts as the surgeon, pathologist, and reconstructive specialist to ensure the most accurate results.

The process involves:

• Staged removal: The cancer is removed one thin layer at a time.
• Microscopic mapping: Each layer is examined under a microscope to trace the cancer down to its roots.
• Total margin control: The surgeon continues until the entire tumor is identified and removed.

The primary goals of Mohs surgery are to:

• Maximize cancer removal: Ensure the entire tumor is gone, significantly minimizing the chance of regrowth.
• Preserve healthy skin: Leave as much healthy tissue unharmed as possible.
• Minimize scarring: Reduce the potential for disfigurement, which is especially important for cancers on the face or hands.

Mohs surgery is most frequently used to treat the two most common forms of skin cancer: basal cell carcinoma and squamous cell carcinoma.

Mohs surgery is named after Dr. Frederic Mohs, professor of surgery at the University of Wisconsin, who developed the surgical technique back in the 1930s. Since then, it has undergone many refinements and has come to be known as “Mohs micrographic surgery” or simply “Mohs surgery” in honor of Dr. Mohs.

To prepare for your Mohs surgery, it is recommended you:

• One week before surgery: Avoid supplements like vitamin E, ginkgo, ginger, garlic, ginseng, and feverfew, as they can thin the blood.
• Three days before and after surgery: Avoid alcohol, which also acts as a mild blood thinner.
• Do NOT stop any medications, including blood thinners, unless directed by your prescribing physician.
• Notify your doctor in advance if you have a pacemaker or defibrillator.

On the day of your surgery, please prepare by adhering to the following:

• Wash the surgical site and surrounding area thoroughly with antibacterial soap and water.
• Avoid lotions, creams, or makeup on or around the treatment area.
• Wear comfortable clothing, ideally a two-piece outfit.
• Due to limited waiting room space, only one person can accompany you.
• You may eat breakfast as normal.

Your Mohs surgery may take between 1 and 5 hours, depending on the complexity of your procedure. Most tumors require 1 to 4 stages for complete removal, with a 1- to 2-hour wait between stages. During this time, the layers that have been collected are examined for remaining cancer cells.

After surgery, you may drive yourself home, as local anesthesia is often used. However, if your procedure was performed near the eyelid, we may recommend that you have a companion drive you home.

Dr. Giuffrida typically recommends taking the day off and, ideally, the following day. This allows plenty of time to heal from the procedure.

Your Mohs surgery will entail the following steps:

1. Dr. Giuffrida administers a local anesthetic at the site of the cancer.
2. Dr. Giuffrida removes the visible tumor with a surgical instrument. He removes a thin layer of tissue with a small margin around the tumor site — this is called the 1^ststage.
3. Dr. Giuffrida makes a map or drawing of the tissue. This is used as a guide to determine the precise location of any remaining tumor cells.
4. Dr. Giuffrida takes the tissue to his lab area within his office. The tissue is sliced into very thin layers and then mounted on microscope slides by a technician. These are then stained to help see the tissue better. There is typically a 1- to 2-hour wait between stages, during which the patient can wait comfortably with a simple bandage in place.
5. The entire margin of the tissue is thoroughly examined with a microscope to check for evidence of remaining cancer cells.
6. If Dr. Giuffrida finds any cancer cells, he returns to the specific area of the tumor and removes another thin layer of tissue from the area where the cancer cells remain.
7. The removed tissue is, again, processed in the lab and examined by Dr. Giuffrida with the microscope.
8. If microscopic analysis still shows evidence of disease, the process continues layer by layer until the cancer is completely removed.

Once there are no further cancer cells seen with the microscope, the patient is evaluated to determine the best option to help the area heal. Because this systematic search reveals the complete “roots” of the skin cancer, Mohs surgery offers the highest chance of complete removal of the cancer while sparing nearby normal tissue.

The Mohs surgery is similar to other surgical procedures because it uses conventional surgical instruments and anesthetics to remove malignant tissue.

There are many differences between Mohs surgery and traditional surgical therapies, including:

• Mohs surgery uses a unique technique to examine tissue after removal, ensuring greater precision.
• It provides a detailed analysis of excision margins in real time, unlike traditional methods.
• This precise approach minimizes guesswork about tumor size and margins, reducing unnecessary tissue removal.
• Mohs surgery lowers the risk of needing repeat procedures or tumor recurrence compared to other therapies.
• It maximizes effectiveness while preserving as much healthy tissue as possible.

The main difference that leads to these benefits lies in how the tissue is examined after removal. Mohs surgery uses a unique microscopic examination technique that sets it apart from other surgical methods. While other specialists may check excision margins, their pathologic examination is not the same as the Mohs process.

Mohs surgery offers the highest potential for cure, up to 99% for new skin cancers and 95% for cancers that have already been treated.

Mohs surgery has the highest cure rate for common cancers like basal cell and squamous cell carcinoma. It is also occasionally used to treat less common tumors.

Dr. Giuffrida may recommend Mohs surgery when:

• The cancer is in an area where it is important to preserve healthy tissue for maximum functional and cosmetic results, such as eyelids, nose, ears, or lips.
• The cancer was treated previously and has come back.
• Scar tissue exists in the area of the cancer.
• The cancer is large.
• The edges of the cancer cannot be clearly seen.
• The cancer grows rapidly or uncontrollably.
• The cancer exhibits aggressive pathology under the microscope.
• The patient is immunosuppressed (such as those with organ transplants or lymphoma).

The entire procedure usually lasts between 1 and 5 hours. If you have a consultation with Dr. Giuffrida before your procedure, he may be able to give you a clearer estimate as to the extent of the timeframe for your surgery.

Yes, any surgical treatment for skin cancer will leave a scar. A benefit of Mohs surgery is that it removes only the cancerous cells and preserves as much healthy skin as possible, which helps to minimize scarring.

Surgical scars improve with time and can take up to 1 year to fully mature. Redness, bumpiness, and hardening of the scar can occur, but these are common and resolve with time. Dr. Giuffrida is available to assist you and address any concerns you may have throughout the healing process.

You and Dr. Giuffrida will determine how the wound will heal best after the cancer has been removed. Dr. Giuffrida is highly skilled in reconstructive surgery for repairing wounds.

Usually, the surgical area is reconstructed with sutures to try to achieve the best possible cosmetic and functional results. This is typically done the same day as the cancer removal. Stitches can be used primarily in three main ways:

1. Direct closure of the wound in which the edges are sutured together side to side.
2. Skin grafting, in which skin is removed from another area of skin and is then placed over the surgical site wound.
3. Skin flap is closing the wound with skin adjacent to the wound.

In certain cases, the wound following Mohs surgery may be allowed to heal on its own. In rare cases, Dr. Giuffrida may refer the patient to another reconstructive surgical specialist.

Once Dr. Giuffrida confirms your skin cancer has been successfully removed, the focus shifts to reconstructing and healing the treated area. Here's what to expect:

• Personalized Healing Plan: Dr. Giuffrida will work with you to determine the best approach for wound healing.
• Expert Reconstruction: Most wounds are repaired the same day using sutures to achieve the best cosmetic and functional results. In some cases, wounds may heal naturally or require referral to another specialist.
• Minimal Pain: Most patients experience only mild discomfort, easily managed with regular Tylenol.
• Normal Recovery Symptoms: Redness, swelling, and/or bruising (especially around the eyes) are common and typically subside within 1–2 weeks. Bruising fully resolves within 1–2 weeks.

If you experience severe pain or sudden swelling, contact our office immediately.