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Mohs’ Micrographic Surgery Your Operation Explained Patient Information Introduction This booklet is designed to give you information about having Mohs’ Micrographic surgery and the care you will receive before, during and after your operation. We hope it will answer some of the questions that you or those who care for you may have at this time. It does not replace the discussion between you and your surgeon but helps you to understand more about what is discussed. What is Mohs’ micrographic surgery? Mohs’ micrographic surgery (called Mohs’ for short) is an operation for certain types of skin cancer. In Mohs’ surgery, the skin cancer is removed a layer at a time until all the cancer cells are gone. The process involves: • A doctor removes a thin layer of skin where the cancer is. The layer removed is processed, which can take about two hours, and this is then looked at under a microscope. • If examination under the microscope shows that some cancer might still be present it is possible to determine precisely where it is. More tissue is then removed from only the area involved and examined. The process continues until there are no signs of any cancer cells left. The surgery itself may only take a short time; however, the process of looking at the tissue can take several hours. Each procedure where tissue is removed and examined is referred to as a stage. When is Mohs’ surgery used? The majority of skin cancers will be removed in an operation without using this technique. Mohs’ surgery is particularly useful for: • Skin cancers of the face and sensitive areas such as the eye where it is important to preserve as much normal tissue as possible. • A cancer where it is difficult to see the extent with the naked eye. • Cancers that have come back in the same place following previous treatment. • Cancers which the doctor thinks have begun to spread into the surrounding area. 2 What are the alternatives? Other treatments for skin cancer include: • Surgery by ordinary removal. • Radiotherapy - directing a beam of radiation at the cancer to destroy it. • Chemotherapy (anti-cancer drugs) applied to the skin • Cryotherapy - freezing the cancer to destroy it. • Curettage and cautery – first the cancer is scraped away (curettage) and then the skin’s surface is sealed (cautery). • Laser surgery (intense beams of light that cut away tissue). • Photodynamic therapy – applying a special cream to the cancer under a dressing for four to six hours, which then destroys the cancer when a special light is shone onto it. These treatment options will already have been considered in your case before deciding on Mohs’ surgery. Your doctor can talk to you about these options. If the cancer is left it is likely to get bigger and may become more of a problem. Treatment is, therefore, usually advisable. What are the benefits of this procedure? The operation is to remove the cancer. Mohs’ surgery removes less healthy skin and tissue while making sure that the cancer has all been taken away. It has an extremely high cure rate (over 95%). What are the risks of this procedure? There are no complications specific to this procedure. Complications of any skin surgery include minor discomfort, wound infection, bleeding, a scar, numbness in the surrounding skin and nerve damage. If there is a high risk of any of these complications, this will be discussed with you before the surgery. The vast majority of patients have this procedure without any problems. Before surgery Please tell us of any medications you are taking and of any illnesses in the past. In particular if you are taking any tablets which thin the blood (aspirin or warfarin), as the wound is more likely to bleed. It is also important that we know if you are allergic to any medication or 3 sticking plaster. The day of surgery It is essential that you allow at least the whole day for the procedure. The length of time you can expect to stay in the department will depend on the number of stages required. Most patients need to have at least two stages. In between stages you will be made comfortable in a waiting area in the department, please bring a dressing gown with you. As it takes time to complete each stage, a book, magazine or something to occupy you may be helpful to pass the time. If possible bring a friend or member of your family to keep you company. Refreshments and a light meal will be provided for you. The procedure The operation will take place in an operating theatre and you will be asked to undress and given a hospital gown to wear. You will be accompanied into theatre and made comfortable. The lesion and surrounding skin will be made numb with injections of local anaesthetic and you should not feel any pain once this is done. Once the doctor is happy that the area is numb the operation will begin. A temporary dressing will be applied to your wound while the removed tissue is prepared and examined. If you require further stages more local anaesthetic injections will be given, as necessary, before repeating the procedure. There will be a wound following completion of the Mohs’ surgery. The way it is closed will depend on the site and size of the wound. In some cases, it is best to leave the wound to heal by itself but the majority will need some stitches, a skin flap or skin graft. It is possible to give some indication before the surgery as to what is likely to be required but the final decision can only be made once the cancer is completely removed. In some cases it is possible to complete the surgery the same day but this is not always possible. However if a wound requires highly specialised closure, it may be necessary to coordinate your care with another surgeon, such as a plastic surgeon, who will close the wound. If this is the case, the wound may not be closed straight away and sometimes there may be a few days delay between your Mohs’ operation and closure of the wound. You will be informed if this is likely to be the case and during this time a dressing will be applied to your wound and you will be given instructions on its care. 4 When will I be able to go home? Normally you should be able to go home soon after the operation is completed. If the wound is on your face, you may find that certain types of dressings can cover your eye or impair your vision. For your safety and that of others please arrange for a friend or relative to take you home after your operation. We advise all patients, following Mohs’ surgery, not to travel home alone. If you are planning to travel home by car, someone else should drive. If you have difficulty arranging transport, please inform the dermatology department before the date of your surgery. What should I do when I get home? When you get home you should rest quietly for the first 12 hours following a small operation or for two to three days following a larger operation. You will be given advice before you leave. You should not drive for at least 24 hours following the anaesthetic, and it may take longer before you feel safe to drive. After surgery Will I experience pain when the local anaesthetic wears off? The anaesthetic may last for two to three hours and will then start to wear off. There may be some mild pain once this happens, but simple pain killers such as paracetamol should be sufficient. Do not take aspirin unless it is prescribed by your doctor for another condition. The pain should not last more than one to two days. If you experience more severe pain or it lasts more than two days, you should contact either your GP or the dermatology department for advice. What should I do if the wound bleeds? A small number of patients will experience some bleeding after their operation. It can usually be controlled by the use of pressure. You should take a gauze pad, paper towel or clean towel 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. If bleeding persists repeat the pressure for another 15 minutes. If there is severe or persistent bleeding, please contact the dermatology department or attend your local Accident and Emergency department. What should I do if the wound becomes infected? 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 becomes more painful or drains 5 pus, please contact your GP or the dermatology department. What should I do if the wound swells? Swelling and bruising are very common following Mohs’ surgery, particularly when performed around the eyes. This usually subsides within four to five days after surgery. What should I do if the area remains numb? At times, the area surrounding your operation site will be numb to the touch as the nerves in the skin have to be cut during surgery. This area of numbness may persist for several months and, rarely, may be permanent. Damage to nerves that affect the muscles is very rare except for deep tumours. Will I have a scar? Although every effort will be made to offer the best possible cosmetic result, skin surgery will leave 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 information sheets that will outline how to take care of your wound. If you have any questions at all, please ask your doctor or specialist. It is important that you make a list of all medicines you are taking and bring it with you to all your follow-up clinic appointments. If you have any questions at all, please ask your surgeon, or specialist nurse. It may help to write down questions as you think of them so that you have them ready. It may also help to bring someone with you when you attend your outpatients’ appointments. For details of local cancer support groups and organisations, please ask your Medical Team. 6 Local sources of further information You can visit any of the health/cancer information centres listed below: Heart of England NHS Foundation Trust Health Information Centre Birmingham Heartlands Hospital Bordesley Green Birmingham B9 5SS Telephone: 0121 424 2280 Cancer Information and Support Centre Good Hope Hospital Rectory Road Sutton Coldfield B75 7RR Telephone: 0121 424 9486 Sandwell and West Birmingham Hospitals NHS Trust The Courtyard Centre Sandwell General Hospital (Main Reception) Lyndon West Bromwich B71 4HJ Telephone: 0121 507 3792 Fax: 0121 507 3816 University Hospital Birmingham NHS Foundation Trust The Patrick Room Cancer Centre Queen Elizabeth Hospital Edgbaston Birmingham B15 2TH Telephone: 0121 697 8417 Walsall Primary Care Trust Cancer Information & Support Services Challenge Building Hatherton Street Walsall WS1 1YB Freephone: 0800 783 9050 7 About this information This guide is provided for general information only and is not a substitute for professional medical advice. Every effort is taken to ensure that this information is accurate and consistent with current knowledge and practice at the time of publication. We are constantly striving to improve the quality of our information. If you have a suggestion about how this information can be improved, please contact us via our website: http://www.birminghamcancer.nhs.uk. This information was produced by Pan Birmingham Cancer Network and was written by Consultant Surgeons, Clinical Nurse Specialists, Allied Health Professionals, Patients and Carers from the following Trusts: Heart of England NHS Foundation Trust Sandwell and West Birmingham NHS Trust University Hospital Birmingham Foundation Trust Walsall Hospital NHS Trust We acknowledge the support of Macmillan in producing this information. © Pan Birmingham Cancer Network 2010 Publication Date: April 2010 Review Date: April 2013 8