Frequently Asked Questions (FAQs)
The most common cause of skin cancer is ultraviolet radiation from the sun. 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.
Both of these cancers behave and are treated similarly. The difference lies in the cell from which each 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 (accounting for 80% of skin cancers) and squamous cell carcinoma is the next most common (accounting for 16% of skin cancers). 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 squamous cell carcinomas can metastasize from the skin. Risk factors for metastasis are dependent on the location of the cancer, size of the cancer and level of compromise in the host’s immune system.
The abnormal growth (cancer) originates in the uppermost layer of the skin. 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 often only a small portion of the total tumor. There are several different subtypes of basal and squamous cell carcinoma. It is important to distinguish these subtypes prior to treatment, as different therapies may be required. For this reason, a biopsy is usually performed prior to any treatment.
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, certain subtypes known as melanoma in-situ, especially in the head and neck region, where Mohs micrographic surgery is beneficial in the treatment of melanoma. Many melanoma in-situ in this region have poorly defined borders, making standard excisions difficult.
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 electrodesiccation (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 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.
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 from 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.
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 you may have. You will be seated on the surgical chair, and the chair will be positioned to a supine position. 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 will be controlled with cautery. The layer of tissue removed will be carefully handled by Dr. Mehrany, diagrammed, and sent to the technician to be processed onto microscope slides. A pressure dressing will be applied over your surgical wound, and you will be free to leave the surgical room. On average, it takes 2-3 hours for the slides to be prepared and analyzed. 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 re-anesthetized for each stage needed. Each stage involves the removal and microscopic examination of your skin for cancer. Therefore, the majority of cases are finished in one day. Once we are sure that we have totally removed your skin cancer, we will then discuss with you our recommendations for dealing with your surgical wound. The wound is then reconstructed the same day. There is no way to tell in advance how much time will be necessary to remove the cancer and repair the wound. As such we ask that you plan to be in the office the entire day and that you make no other commitments.
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 painkiller. 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 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 that 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 an area where adhesive tape has been applied, are not uncommon. If this occurs, ask your 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.
After having one skin cancer, statistics show that you have a higher risk of developing another skin cancers. Studies show that when a person presents with a skin cancer, they have a 50% chance of developing another skin cancer within five years. Simply put, this means that half the patients that presented to have a skin cancer treated subsequently had another skin cancer diagnosed within five years. The damage your skin has already received from the sun cannot be reversed. However, it is never too late to start using good sun protection and sun screen use to help decrease the risk of developing further skin cancers.
Skin cancer is the most common form of cancer. In fact, skin cancer is more common than all other cancers combined. Over 5 million new cases of skin cancer are diagnosed each year in the United States.
The treatment of any skin cancer takes four main goals into consideration:
A. Complete removal of the cancer
B. Maximal preservation of normal skin
C. Maximal preservation of function
D. Optimal cosmetic outcome
Mohs surgery provides the best attainable results for each of these four goals and is therefore considered the “gold standard” for treating skin cancer.
Any form of surgery has it’s associated risks. Since Mohs surgery is performed as an outpatient surgery, under local anesthesia, with the patient awake, it is safer than most other forms of surgery. There will be a scar after the surgery. We use plastic and reconstructive surgery techniques to hide or minimize scars as much as possible. Scars mature and fade considerably over time. If the results are not satisfactory after several months, then a surgical revision can be performed, however this is very rarely necessary. Bleeding, infection or nerve injury can also occur with any form of skin surgery.
If the cancer is not treated then the tumor will enlarge and invade and eventually produce problems such as pain, bleeding or infection. The rate that a cancer grows is unpredictable as it depends on two extremely variable factors: the aggressiveness of the cancer and the patient’s immune response against the cancer. The larger a cancer is allowed to grow, the more likely it will require extensive reconstruction after removal. With time, most cancers gradually penetrate deeply into the body and, if neglected, some can spread to distant sites.
Take all of your medications prescribed by your doctor including blood thinners like aspirin or Coumadin per routine. However, if you are taking, aspirin, ibuprofen, vitamins or herbal supplements (ie. Anacin, Bufferin, Excedrin, Alka Seltzer, Percodan, Advil, Aleve, Motrin, Multi-Vitamins, Vitamin E and Ginko Bilboa) without your doctor’s orders then please discontinue them 10 days prior to the surgery appointment. You may take Tylenol as needed for pain. Alcohol also promotes bleeding so please avoid alcoholic beverages 48 hours before surgery. Make-up, moisturizers, sun screen, perfume, cologne and jewelry should not be worn on the day of surgery. Wear comfortable clothing; a blouse or shirt that buttons rather than one that slips over the head is best. Please shower and wash your hair prior to the surgery as bandages may need to be kept dry for 1 week after the surgery. You will be in the office most of the day; therefore, you may want to bring a snack or lunch with you. Also, you may want to bring your favorite reading material, iPad, smart phone, head phones or head set to keep you entertained as there is a good deal of waiting involved while your tissue is being processed.
After surgery, the operative site is covered with a pressure dressing that stays on the entire week. Upon return to the office one week after surgery for postoperative follow up then the pressure dressing is removed. If necessary, sutures will be removed from head and neck wounds at the one week postoperative appointment. For wounds on the trunk and extremities sutures are typically removed two weeks after surgery. Additional check-ups may be required depending on the size and complexity of the reconstruction. You will need to refrain from strenuous activity for 1-2 weeks following the surgery.
The best protection from skin cancer is to avoid the sun’s harmful ultraviolet rays. These ultraviolet rays of the sun contribute to skin cancer formation in two ways. First, the ultraviolet rays damage the genes that control cell growth causing the cells to divide uncontrollably. Second, the ultraviolet rays damage the body’s immune system such that early cancers grow unchecked by the immune system defense surveillance.
One can minimize their exposure to ultraviolet sun rays by:
1- Using any sunscreen with a sun protective factor (SPF) of 30 or greater
2- Using a “broad spectrum sunscreen” which means that the sunscreen protects against both ultraviolet A (UVA) and ultraviolet B (UVB) rays
3- Avoid sun exposure during the middle of the day (10:00 am – 4:00 pm) when the ultraviolet rays are the strongest
4- Do not remain outdoors unprotected on cloudy days since ultraviolet light penetrates easily through the clouds
Educational Links
American College of Mohs Surgery
https://www.mohscollege.org/for-patients
American Academy of Dermatology
https://www.aad.org/public/diseases/skin-cancer
Skin Cancer Foundation
American Cancer Society
American Society of Dermatologic Surgery