San Jose Office (408) 335-3966
Modesto Office (209) 338-7758
Cancer is the abnormal growth of cells at an uncontrolled and unpredictable rate. The cancer tissue usually grows at the expense of surrounding normal tissue. In the skin, the most common types of cancers are basal cell carcinoma and squamous cell carcinoma. The names reflect the cell within the skin from which the particular type of skin cancer originates. Malignant melanoma or a “cancerous mole” is a rarer type of skin cancer that usually appears as a dark colored spot or bump on your skin and slowly enlarges. In the Mohs Surgery office, we treat basal cell carcinomas, squamous cell carcinomas, malignant melanoma, and some more unusual skin tumors.
WHAT IS BASAL CELL AND SQUAMOUS CELL CARCINOMA?
Both
of these cancers behave and are treated similarly. The difference lies in the
cell from which it originates within the skin. Often, this can only be distinguished
by examining the skin under a microscope. Basal cell carcinoma is the most
common cancer of any type, with about one million new cases a year in the U.S.
Both basal and squamous cell carcinoma most commonly occur on the head and
neck. The carcinoma often begins as a small bump that can look like a pimple,
but will continue to enlarge, often bleeds, and does not heal completely. It
may be red, flesh-colored, or darker than the surrounding skin. Basal cell
carcinoma rarely spreads (metastasizes) to distant parts of the body. Instead,
it grows larger and deeper, destroying nearby parts of the body in its path.
Squamous cell carcinoma behaves locally like basal cell carcinoma. However,
certain tumors can metastasize from the skin.
The
abnormal growth (cancer) originates in the uppermost layer of the skin. The
cancer then grows downward, forming root and fingerlike projections under the
surface of the skin. Unfortunately, at times these roots are so subtle they
cannot be seen without the aid of a microscope. Therefore, what you see on your
skin is sometimes only a small portion of the total tumor. There are several
different types of basal and squamous cell carcinoma. It is important to
distinguish these types prior to treatment, as different therapies may be
required. For this reason, a biopsy is usually performed prior to any
treatment.
Like
other cancers, the cause of skin cancer is unknown. The most common association
with skin cancer is long-term exposure to sunlight. This is why skin cancers
develop most often on the face and the arms (sun-exposed body parts). They
occur more commonly in fair-skinned people than dark-skinned people and in the
United States they are found more frequently in the southern (sun-belt) areas.
Radiation therapy, trauma (scars), certain chemicals and rare inherited diseases may also
contribute to the development of skin cancer.
Melanoma
is the deadliest skin cancer accounting for two-thirds of all deaths attributed
to skin cancers. The standard treatment for melanoma is local excision of a
margin of normal appearing skin surrounding the melanoma. There are, however,
special cases, especially on the head and neck region, where Mohs micrographic
surgery is beneficial in the treatment of melanoma. Many of the melanomas in
this region have poorly defined borders making standard excisions difficult.
Mohs
Surgery in the treatment of melanoma is modified. The initial stages done by
frozen sectioning is the same as for other skin cancers.
At
the conclusion of the standard Mohs Surgery, however, an additional rim of
tissue maybe removed for additional histological examination that can take a few
days to process. This additional step allows for a more precise treatment of
the melanoma.
Accordingly,
the reconstruction will be delayed until this final rim of tissue is cancer
free.
HOW SUCCESSFUL IS THE TREATMENT OF SKIN CANCER?
Initial
treatment of skin cancers has a success rate greater than 90 percent. Methods
commonly employed to treat skin cancer include excision (surgical removal and
stitching); curettage and electrodessication (scraping and burning with an
electric needle); cryosurgery (freezing); and radiation therapy (“deep x-ray”).
The method chosen depends upon several factors, such as the microscopic type of
the tumor, the location and size of the cancer and previous therapy. You may
have had one or more of these methods of treatment before coming for Mohs
Surgery.
If
a skin cancer previously treated by one of the above techniques recurs (comes
back), retreating using these methods has a success rate of less than 75
percent.
The
success rate for Mohs Surgery, even in treating these recurrent lesions, is
about 97-98 percent. Mohs Surgery (discussed in detail later) is very time
consuming and requires a highly trained team of medical personnel. The vast
majority of Mohs surgeons are dermatologists who have had extensive fellowship
training after completing their dermatology training. Dr.
Mehrany is a fellowship trained Mohs Surgeon and is a member of the American
College of Mohs Micrographic Surgery and Cutaneous Oncology. Many skin cancers
that are easily/effectively treated by the other methods listed previously do
not require Mohs Surgery. Mohs Surgery is reserved for recurrent skin cancers
or for primary skin cancers which are difficult to treat initially with other
therapies.
HOW DO I PREPARE FOR THE DAY OF SURGERY?
The
best preparation of Mohs Surgery is a good night’s rest followed by breakfast.
In most cases, the surgery will be completed on an outpatient basis. Because
you can expect to be here for most of the day, it is wise to bring along a book
or magazine, as well as something to eat for lunch. If you prefer there are a
few restuarants that are within 5 minutes from the office. Also, because the
day may prove to be quite tiring, it is advisable to have someone accompany you
the day of surgery to provide companionship and a ride home.
You
may be asked to have a preoperative visit to discuss your surgery. At this
visit, the technique will be discussed in detail, a biopsy may be performed (if
it has not already been done) and necessary paperwork will be finished
(consents, insurance forms, etc.).
If
you are coming a great distance and/or are being referred by a physician
familiar with the technique, you may be referred directly for Mohs Surgery
without a preoperative visit.
We
request that you stop taking any aspirin, ibuprofen, or Vitamin E compounds (like
Anacin, Bufferin, Advil, Motrin or multi-vitamins) at least one week or preferably two weeks
before your surgery. This is because it may interfere with the normal blood
clotting mechanism, making you bleed more than normal during surgery. If a
physician prescribes your aspirin, please notify your physician before
discontinuing the aspirin.
The cost of Mohs Surgery and reconstruction is borne by most insurance carriers as it is medically necessary.
WHAT HAPPENS THE DAY OF SURGERY?
Your
appointment has purposely been scheduled early in the day. Upon your arrival
you should check in at the front desk. Once the surgery room becomes available,
you will be escorted by our medical assistant to that area of the office. If
you have not had a prior consultation visit, Dr. Mehrany will allow time before
the surgery to go through the procedure with you and answer any questions that
you may have.
After
preliminary preparation of the skin, you will be placed on the surgical chair
and the area around your skin cancer will be anesthetized (numbed) using a
local anesthetic. This may be uncomfortable, but usually this is the only pain
you will feel during the procedure. Once the area is numbed, a layer of tissue
will be removed and the bleeding controlled. The layer of tissue removed will
be carefully handled by the surgeon, diagrammed, and sent to the technician to
be processed into microscopic slides. A pressure dressing will be applied over
your surgical wound and you will be free to leave the surgical room. On the
average, it takes 1-2 hours for the slides to be prepared and studied. During
this time you may wait in the front waiting room.
Most
Mohs Surgery cases are on average completed in two or three stages. You will be
reanesthetized for each stage needed. Each stage involves the removal and
microscopic examination of your skin for cancer.
Therefore,
the majority of cases are finished during one day. Once we are sure that we
have totally removed your skin cancer, we will discuss with you our
recommendations for dealing with your surgical wound. Often, the wound can be
closed the same day.
WHAT CAN I EXPECT AFTER THE SURGERY IS COMPLETE?
Pain
Most
people are concerned about pain. You will experience remarkably little
discomfort after your surgery. Due to its potential to cause bleeding, we
request that you do not take aspirin, but use Tylenol or a Tylenol-like pain
killer. Rarely will a stronger pain medicine be prescribed.
Bleeding
A
small number of patients will experience some post-operative bleeding. It can
usually be controlled by the use of pressure. You should take a gauze pad and
apply constant pressure over the bleeding point for 15 minutes; do not lift up
or relieve the pressure at all during that period of time (no peeking). If
bleeding persists after continued pressure for 15 minutes, repeat the pressure
for another 15 minutes. If this fails, then apply a third round of 15 minutes
of pressure.
Finally,
if the bleeding persists then Dr. Mehrany can be reached 24 hours a day by
calling his cell phone. If you are unable to directly contact
Dr. Mehrany then visit a local emergency room for assistance. Your wound care
instructions (given at the end of surgery) will also list his phone number if
you have questions.
Complications
There
are some minor complications which may occur after Mohs Surgery. A small red
area may develop around your wound. This is normal and does not necessarily
indicate infection. However, if the redness does not subside in two days or the
wound begins to drain pus, you should notify Dr. Mehrany immediately.
Itching and redness around the wound, especially in area where adhesive tape has been applied, are not uncommon. If this occurs, ask you pharmacist for a non-allergenic tape and tell us on your return visit.
Swelling and bruising are very common following Mohs Surgery, particularly when performed around the eyes and mouth. This usually subsides within four to five days after surgery and may be decreased by the use of an ice pack in the first 24 hours.
Numbness
At
times, the area surrounding your operative site will be numb to the touch. This
area of numbness may persist for several months or longer. In some instances it
may be permanent. If this occurs, please discuss it with Dr. Mehrany at your
follow-up visit.
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 of your
wound.
We
will discuss wound care in detail with you and give you a Wound Care
Information Sheet, which will explicitly outline how to take care of whatever
type of wound you have.
WILL I DEVELOP MORE SKIN CANCERS?
After
having skin cancer, statistics say that you have a higher chance of developing
another. The damage your skin has already received from the sun can not be
reversed. However, there are precautions that can be taken to prevent further
skin cancers. They involve good common sense. You should use a sunscreen applying
it at least 10 minutes before exposure to sunlight.
The
sunscreens are now labeled as to strength; the higher numbers are more
protective. We would recommend that you use a #30 or higher SPF sunscreen.
Despite manufacturers’ claims, we recommend that you reapply sunscreen every
two hours when in the sun and after swimming. A wide-brimmed hat, long sleeved
shirt and other protective clothing are also appropriate. Avoiding excess
sunshine is recommended.
You
should have your skin checked very closely by your referring physician 2-3 months after our surgery. This is not only to check the surgical site as it is healing, but
also to check for the development of additional skin cancers. Our policy is for
us to follow the majority of our patients until the wound has healed, and then
they can continue to be followed very well by their referring physician.
We
recommend 3-6 month follow-up visits for two years, then yearly. Of course,
any area of your skin that changes, fails to heal, or just concerns you should
be brought to the attention of your referring physician immediately. He or she
will be able to adequately determine most skin cancers when they are detected
early and are small.