Download Mohs Surgery Patient Info Pack

MOHSMICROGRAPHICSURGERY:PATIENTINFORMATION
DanielleK.Moul,M.D.,F.A.A.D.
DearPatient:
YourdoctorhasreferredyouforMohssurgery,averyeffectivetreatmentavailableforskin
cancer.TheMohssurgerynotonlyprovidesahighcurerate(98-99%)formostprimarytumors,
butalsopermitsoptimalcosmeticresultsbyminimizingtheamountoftissueremoved.
ThispamphletwillfamiliarizeyouwiththeMohsprocedure,andtellyouwhattoexpectwhen
youcomeforsurgery.Itwillalsoteachyouaboutthecausesofskincancer,andhowto
recognizeitandhowtopreventit.Ifyouhaveanyquestionsthatarenotansweredbythis
booklet,pleasefeelfreetocallourofficeatanytime.
Sincerely,
DanielleK.Moul,M.D.,F.A.A.D.
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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WhatisSkinCancer?
Canceristissuecomposedofabnormalcellsthatgrowatanuncontrolledandunpredictablerate.As
cancerousormalignanttissuegrows,itinvadesanddestroysthesurroundingnormaltissue.Themost
commontypesofskincancerare:
Basalcellcarcinoma–commonlyappearsasapearlywhite,pinkorredpatchorbumpthatmay
bleedorscabrepeatedly.
• Squamouscellcarcinoma–typicallyafirm,redbumporpatchwithacrustysurface.
• Malignantmelanoma–usuallyabrownish-blackpatchorbumpthatenlarges,changesinshape
size,colorand/ormaybleed.
Thesecancersoriginateintheskin,but,ifneglected,caninvadeanddestroymuscle,boneandother
structures.Metastasisisthemigrationofthecancercellbeyondthesiteofitsoriginalgrowthorlesion.
Basalcellcarcinomasrarelymetastasize;squamouscellcarcinomascanmetastasizeatarateofabout
2-5%especiallyifleftuntreated.Malignantmelanomacanmetastasizeandislifethreateningifnot
treatedearly.Unliketheotherformsofcancerininternalbodyorgans,skincancercanbeseenwithout
theaidofsophisticatedmedicalequipment.Thisallowspatientsortheirdermatologisttoidentifythe
problemandseektreatmentearlywhilethecancerisstillsmallandeasilycured.
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WhatisaBiopsy?
Abiopsyistheremovaloftissuefromthebodyforpurposesofdiagnosisbymicroscopicexamination.
Therearemanybenign(non-malignant)skingrowthsorlesionsthatmaydisplaysomeofthesignsof
skincancerlistedabove,butthatareobviouslynotcancerwhenseenunderthemicroscope.Inmany
cases,abiopsyistheonlywaytodistinguishbetweenacancerandabenign(non-malignant)moleor
wart.Usually,onlyasmallportionofaskingrowthisremoveduponbiopsy,soadditionalsurgeryis
requiredtoremovetheremainderifitprovestobecancerous.
HowisSkinCancerTreated?
Techniquesforthetreatmentofskincancerincludecurettageandelectrodessication(scrapingawaythe
canceroustissuewithasurgicalinstrument,andthenusingcauterytostopthebleeding),surgical
excision(cuttingoutcanceroustissue),cryotherapy(freezingwithliquidnitrogen),topicalcreams(such
as5-Fluorouracilorimiquimodcreamapprovedforsuperficialbasalcellcarcinoma),radiationtherapy,
suchaselectronicbrachytherapy(eBx),andMohsmicrographicsurgery.
WhatisMohsMicrographicSurgery?
MohsmicrographicsurgeryisnamedinhonorofDr.FredericMohs,thephysicianwhodevelopedthe
techniqueinthe1930s.Thetermschemosurgery,Mohssurgeryandmicroscopicallycontrolledsurgery
allrefertothesametechnique.IntheyearssinceDr.Mohspioneeredtheprocedure,manytechnical
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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improvementsandrefinementshavecontributedtomakemicrographicsurgeryasafeandhighly
effectivemeansoftreatingskinmalignancies.
Themaindifferencebetweenmicrographicsurgeryandothermethodsofremovingskincanceris
microscopiccontrol.InMohssurgery,canceroustissueisremovedinthinhorizontallayers.Eachlayer
isdividedintosections,andeachsectioniscarefullyidentifiedand“mapped”bythesurgeonsoitsexact
locationcanbepinpointedonthewound.
Aftercarefulpreparationinthelaboratory,Dr.Moulinspectseachtissuesectionunderthemicroscope.
Aslongascancercellsareseenwithinasection,thenDr.Moulcontinuestoremoveandexaminetissue
layersfromthatpartofthewound.BecauseeachlayerisexaminedmicroscopicallytheMohssurgery
providesthehighestcurerate.Inaddition,becausenohealthytissueisremovedunnecessarilysuperior
cosmeticresultscanbeachieved.
WhataretheadvantagesofMohsMicrographicSurgery?
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Highcurerate(98%-99%)
Smallestpossiblewound
Optimalcosmeticresult
Convenient:cancerremovedinoneoutpatienttreatmentsession
Cost-effective:fewercancerrecurrences-fewerreturnvisits.
Safe:avoidsrisksofgeneralanesthesia
WhichSkinCancersShouldBeTreatedWithMohsSurgery?
Mohsmicrographicsurgeryisnowuniversallyrecognizedasapreciseandeffectivemethodoftreating
skincancers.Itisespeciallyeffectiveintreatingcancersofthefaceandothercosmeticallysensitive
areasbecauseitcaneliminatecancercellswhilecausingminimaldamagetothesurroundingnormal
skin.
Mohsmicrographicsurgeryisalsoidealforrecurrentskincancers,thosethatgrowbackafterprevious
treatment.Whileskincancersareofteneasilyvisible,individualcancercellsaremicroscopic.Root-like
extensionofcancercellsmayreachbeyondthecancer’svisibleborderswithnestsofcellsgrowingin
unpredictableareas.Therefore,whatisapparenttothenakedeyeonthesurfaceoftheskinmay
actuallybeonthe“tipoftheiceberg”.Anycellsleftbehindcancausethecancertorecur,justasroots
leftbehindwhenpullingweedsmaycauseweedstoregrow.WiththeMohstechnique,tumornestscan
beidentifiedandremovedwithahighdegreeofaccuracy,producingextremelyhighcurerates,ashigh
as94-98%evenforrecurrentskincancers.YourdermatologisthasreferredyoutoDr.Moulbecause
he/shefeelsthatMohsmicrographicsurgeryisthebesttreatmentforyourskincancer.
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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WhoPerformsMohsMicrographicSurgery?
TheAccreditationCouncilforMedicalGraduateEducation(ACGME)hasrecognizedalimitednumberof
trainingprogramsintheUnitedStateswherehighlyqualifiedapplicantsreceivecomprehensivetraining
inMohsmicrographicsurgerythroughaProceduralDermatologyfellowship.Thetrainingperiodis
usuallyoneyear,duringwhichtimethedermatologistacquiresextensiveexperiencewithallaspectsof
theMohstechnique.Oncethephysician’strainingissuccessfullycompleted,heorshebecomeseligible
formembershipintheAmericanCollegeofMohsMicrographicSurgery(ACMS).
AboutDr.Moul
Dr.Moulisafellowship-trainedMohssurgeonandboardcertifieddermatologist.Dr.Moulcompleteda
prestigiousMohsSurgery/ProceduralDermatologyFellowshipatScrippsclinicinLaJolla,California.Her
fellowshipisapprovedbyboththeAmericanCollegeofMohsMicrographicSurgery(ACMS)andthe
AccreditationCouncilforGraduateMedicalEducation(ACGME).ShetrainedunderDr.HughGreenway,
who,hehimselfwastrainedbyDr.FredericMohs.Dr.Moulhashadextensivetraininginfacial
reconstructionincludingskinflapsandgrafts.ShehasworkedincollaborationwithPlasticSurgery,
Oculoplastics,Otolaryngology,andRadiationOncology.Shehasexperienceinmanagingcomplicated
tumorssuchasrecurrenttumors,tumorspreviouslytreatedwithradiation,andraretumorsincluding
merkelcellcarcinoma,sebaceouscarcinomaanddermatofibrosarcomaprotuberans.
ShehaspublishedabookchapterinInternationalOphthalmologyClinicsonMohsMicrographicSurgery
forPeriorbitalSkinCancer.Inaddition,shewasselectedtopresentresearchontheimportanceofprebiopsysitephotographattheAmericanSocietyofDermatologicSurgery’snationalmeeting,whichwas
alsopublishedas“Whereisit?Theutilityofbiopsy-sitephotography”.SheisamemberoftheAmerican
BoardofDermatology,AmericanCollegeofPhlebology,AmericanDermatologicSurgeryandAmerican
CollegeofMohsSurgery.Hergoalistoprovideyouwiththebestpossiblecareavailable.Shewelcomes
anyquestionsorconcernsyoumayhave.
HowShouldIPrepareforSurgery?
Ifyouaretakingmedication,continuetakingitasprescribedunlesswedirectotherwise.Ifyouare
takingCoumadinorwarfarin,Eliquis®Pradaxa®,orXarelto®pleasenotifytheoffice.Ifyouhavenothad
aheartattack,stentorstroke,etc.,andaretakingitforpreventiononlypleasediscontinueaspirinand
medicationsthatcontainaspiring(Anacin®,Bufferin®,Excedrin®,Alka-Seltzer®,etc.)foratleasttendays
(10)dayspriortoand5daysfollowingsurgery.Alsoavoidanti-inflammatorymedications(Advil®,
Aleve®,diclofenac,Ibuprofen,Nuprin®,indomethacin,Naprosyn®,etc.forthesametimeperiod.These
medicationstendtoincreaseandprolongbleedingduringsurgeryandmayinterferewithwound
healing.YoumaytakeTylenol®(acetaminophen).Alcoholicbeveragesshouldbeavoidedfor72hours
priortoand72hoursfollowingsurgeryasalcoholdilatesbloodvesselsandcanpromotebleeding.
PleasediscontinueCoQ10,vitaminE,fishoilandSt.John’swortfor10dayspriortosurgeryand5days
followingthesurgery;thesevitaminscanincreaseyourriskofbleeding.
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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Ifyouhaveaheartmurmur,anartificialheartvalveoranyartificialjointsorimplantswiththepast2
years(otherthanpacemaker),youwillneedtotakeanantibioticthedayofsurgerytopreventinfection.
Pleasenotifyussothatthismaybeprescribedinadvance.Getagoodnight’srest,eatbreakfastand
cometotheofficeatyourscheduledtime.
TheDayofSurgery
Surgeryusuallybeginsearlyinthemorningsothatthesurgicalstagescanbecontinuedthroughoutthe
day,ifnecessary.Youshouldplantospendtheentiredaywithus.Pleasedon’tmakeother
commitmentsfortheday.Surgeryisnearlyalwaysfinishedthesameday,unlessthetumorisextensive
oramoreinvolvedrepairisrequired.WhilethelengthoftimerequiredforMohssurgeryisinitially
surprisingandperplexingtosomepatients,thefollowingdescriptionoftheprocessgenerallyalleviates
suchconcerns.
First,alocalanestheticisusedtonumbtheskinaroundthetumortopreventdiscomfortduringsurgery.
Ifyousufferfromanxietyornervousabouttheprocedure,pleaseletyourdoctorknowsotheymay
prescribemedicationifneeded.Whentheskinisnumb,Dr.Moulthenremovesalayeroftissue
involvedbythecancer,bleedingisstoppedwithelectrocoagulation,andadressingisapplied.The
proceduretothispointtypicallyrequires10-15minutesforeachtimetumorisremoved.
Theremovedtissueissenttothelaboratorywhereitispreparedformicroscopicexamination.
Laboratorypreparationandexaminationunderthemicroscopearedelicateproceduresandrequire
greatprecision.Theyarealsotime-consumingapproximatelyanhourisrequiredeachtimetissueis
excised.
Themostdifficultpartoftheprocedureforyouwillbewaitingfortheresultsofthemicroscope
examination.Youwillwanttowearcomfortableclothing,considerbringingasnackorlunch,aswellas
readingmaterial,IPAD,computer,paperwork,crosswordpuzzlesorotheractivitiestohelppassthe
time.
Ifforsomereason,youmustleavetheoffice,itisveryimportantthatyoufirstcheckwithanurseand
leaveanumberwhereyoucanbereached.Pleasebringafriendorarelativetodriveyouhomeafter
thesurgeryifyouarehavingsurgerynearyoureye,areanxiousabouttheprocedureandreceivinga
sedativeorrequireextraassistance.
Oncetheskincanceriscompletelyremoved,Dr.Moulwilldiscusswithyoutheoptionsformanagement
ofthesurgicalwound,usuallytherearetwochoices:letthewoundhealbyitselfwhichusuallytakes4
to12weeksorclosethewoundwithstitches.Dependingonyourwounditmaybeclosedsidebyside,
byaskipflap(tissuemovedfromnearbyskin)oraskingraft(tissueremovedfromanothersiteand
transferredtothewound).Aside-to-sideclosureisthemostcommonclosureandisknownasa
complexlinearclosure.Complexlinearclosuresaretypically3timesthelengthasthewidthofthe
wound.Youwillnoticeyourincisionis3timeslongerthanthesizeofthedefect.Thisissothescarwill
healintoafinethinlinewithouttheendsbeingraised.Dr.Moulwillrecommendwhichofthesechoices
willbebestinyourcase.Ifitisdeterminedthatthewoundshouldberepaired,thisisusuallyperformed
byDr.Moulthesameday.
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ThePost-OperativeCourse
Sinceyouwillprobablybefatiguedyoushouldplanontakingiteasyandgettingplentyofrestthefirst
night.Mostpatientsdonotcomplainofpain.TwoTylenol(1,000mgacetaminophen)takenevery6
hoursareusuallysufficienttorelievethediscomfortsomepatientsexperiencethefirst12to24hours.
Swellingandbruisingareverycommon,particularlywhensurgeryisperformedonthenoseoraround
theeyes,andgenerallyresolvewithinaweekto10days.Painlessred,purpleoryellowbruisingand
swellingoftheeyelidsoftenappear2-3daysaftersurgeryontheforehead,frontportionofthescalp,
noseortemplesandarenocauseforconcern.Theuseofextrapillowsthefirst4nightsfollowing
surgerytokeeptheheadandshoulderselevatedwhilesleepingandicepackswrappedintowelsas
toleratedfor10minutesatatimehelpminimizethis.
Veryoccasionallythereiscontinuedbleedingfollowingthesurgery.Ifthisoccurs,liedownandremove
allthebandages,andwithgauze,applyfirm,steadypressurefor20minutes(timed)overtheareaofthe
woundthatisoozingblood.Donotliftthegauzetocheckonthebleedingbefore20minuteshave
passed.Ifthebleedingpersistsafter20minutesofsteadypressure,immediatelynotifyouroffice,orgo
tothenearesthospitaloremergencyroom.
Allwoundsnormallydevelopasmallhaloofrednessaroundthem,whichgraduallydisappears.If
increasingredness,warmth,tendernessorpaindevelop,thewoundismalodorous,orthereispus
drainingfromthewound,callourofficeimmediately.Thewoundmayhavebecomeinfectedandan
antibioticmaybenecessary.Iftheskinaroundthewoundbecomesveryitchyandred,youareprobably
havingareactiontotheadhesivetapeortheantibioticointmentusedtodressthewound.Youshould
callourofficeifthisoccurs.
AftertheWoundHasHealed
Somepatientsmayexperiencesensationsoftightness,numbness,tingling,sensitivitytothe
temperaturechange,oritchingaroundthesurgicalsite.Thesesensationsarenormalandtendto
improvewithtimeoverseveralmonths.Gentlymassagingthesiteseveraltimeseachdaycanspeedup
theprocess,however,thisshouldnotbedoneuntilatleast3weeksaftersurgeryasadvisedbyDr.
Moul.ItchingmaybeduetodrynessandcanbeimprovedwithplainVaseline.Rednessatthesiteis
alsonormalandwillgraduallyfade,usuallyby6months.
Afollow-upperiodofregularskinchecksatintervalsofevery6monthstoyearlyisessential.50%of
patientswilldevelopanotherskincancerintheirlifetime.Therefore,patientsreturntotheir
dermatologist,forexaminationtodetectanyneworrecurrentskincancersandtreatthemintheirearly
stages.Besuretoreportimmediatelytoyourdermatologistanysuspiciouslesionsyouhavenoticedon
yourskintoseeifabiopsyisnecessary.
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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CommonlyAskedQuestions:
1. WilltheSurgeryLeaveaScar?
Yes.Anysurgicaltreatmentwillleaveascar.However,theMohstechniquetendstominimizethisas
muchaspossibleandDr.Moulisspeciallytrainedinthereconstructiontominimizescarring.
2. ShouldPlasticSurgeryBePerformed?
Dr.Moulisafellowship-trainedMohssurgeonwhohascompletedaprestigiousfellowshipatScripps
clinicinLaJolla,California.HertrainingincludedcarefulevaluationsofMohsdefectsandfacial
reconstructionincludingflapsandgrafts.Shehasworkeddirectlywithplasticsurgery,oculoplastic
surgeryandENTandhasbeentrainedtohelpprovideyouwithoptimalcosmeticresults.Theoverall
cosmeticappearancewillcontinuetoimproveforatleastayearaftersurgery.Inrareinstancesyour
repairmaybecoordinatedwithaplasticsurgeonifthesurgicalwoundrequiressedationorisalarge
defectrequiringarepairinanoperatingroom.
3. MohsMicrographicSurgeryPreoperativeChecklist
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10dayspriortosurgery
1. IfyouhaveNOThadaheartattack,stent,bloodclotorstrokeandtakingitpurelyfor
preventionstopaspirinandaspirin-containingmedications(includingExcedrin®,
Bufferin®,Alka-seltzer®,Ecotrin®,etc.)
2. StoptakingCoQ-10,VitaminE,FishOil,orSt.John’swortsupplements
3. IfyouareonCoumadinorwarfarin,pleasenotifytheofficeofyourrecentlabwork,INR.
4. IfyouaretakingEliquis®,Pradaxa®orXarelto®,pleasenotifytheoffice.
5. Stopanti-inflammatorypainmedications(includingAdvil®,Aleve®,Ibuprofen,
Naprosyn®,andDaypro®etc.
Continueallotherprescriptionmedications.
Cancelothercommitmentsforthedayofsurgery–you’llwanttotakeiteasyforatleast24
hours.
72Hoursbeforeandaftersurgery:discontinuealcoholicbeverages
Arrangeforaridehomeafterthesurgeryifneeded
Fillanypreviouslyorderedprescriptionsforpre-operativeantibioticsand/orsedatives
Eatbreakfastandtakeyourusualmedications(exceptthoselistedabove)thedayofsurgery
Itisagoodideatobringasnackorlunch.
Bringreadingmaterial,paperwork,IPAD,laptop,Kindle,etc.
PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com
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