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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 1 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. • 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 2 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? • • • • • • 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 3 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 4 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. PHONE:888.411.DERM(3376)•EMAIL:[email protected]•WEBSITE:SkinMDs.com 5 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 6 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 • • • • • • • • • 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 7