Listed below is information about preparing for Mohs surgery and how to care for your wound after the surgery.  We strongly recommend that you review all of this information prior to your procedure. Please let us know if you have any questions.

• What is Mohs Surgery?
• Risks of Mohs Surgery
• How to Prepare for Mohs Surgery
• About Dr. Aerlyn Dawn
• Mohs Wound Care

MOHS SURGERY

What is Mohs surgery?
Mohs surgery is a highly specialized treatment for the total removal of skin cancer.  This method differs from all other methods of treating skin cancer by the use of complete microscopic examination of all of the tissues removed surgically as well as detailed mapping techniques to allow the surgeon to remove all of the roots and extensions of the skin cancer.

The procedure is begun after the skin is injected with a local anesthetic to make it completely numb.  Then, the visible cancer and a very thin layer of skin are removed with a scalpel, carefully mapped, and examined microscopically.  If there is still cancer seen under the microscope, another very thin layer of skin is removed from that exact location.  This may be repeated as often as necessary to completely remove the cancer.

What are the advantages of Mohs surgery?
By using these detailed mapping techniques and complete microscopic control, the Mohs surgeon can pinpoint areas involved with cancer that are otherwise invisible to the naked eye.  Therefore, even the smallest microscopic roots of cancer can be removed.  The result is: 1) the removal of as little normal skin as possible and 2) the highest possibility of curing the cancer.

What is the cure rate?
Mohs surgery is the most accurate method for removing skin cancers, even when previous forms of treatment have failed.  In untreated cancers the percentage of cure is 99 percent.  In previously treated cancers, where other forms of treatment offer only an 80 percent chance of success, Mohs surgery is 95 percent effective.

Is hospitalization necessary?
No.  Mohs surgery is performed in a pleasant outpatient surgical suite and you may return home the same day.

How long does Mohs surgery take?
Your appointment will be scheduled early in the day. The staff will escort you into a surgical suite where the surgeon will numb the area around the skin cancer. Once it is numb, the visible cancer and a thin layer of tissue will be removed.  This tissue is carefully mapped and coded by the surgeon and taken to the adjacent laboratory where the technician will immediately process the microscopic slides.  You will have a temporary dressing placed over the wound and you will be free to return to the waiting room.

The surgical procedure alone takes only 10-15 minutes.  However, it takes a minimum of 1-2 hours to prepare and microscopically examine the tissues.  Several surgical stages and microscopic examinations may be required, and you will be asked to wait between stages.  Although there is no way to tell before surgery how many stages will be necessary, most cancers are removed in 3 stages or less.

We would like to make the time you spend as pleasant and comfortable as possible.  You may want to bring reading material to occupy your time while waiting for the microscopic slides to be processed and examined.  Magazines are generally available in the waiting room areas.  If you visit extends through the lunch hour, your companion may visit a nearby café and bring you a snack or lunch at most practices.

The most difficult part of the procedure is waiting for the results of the surgery.  Since no one knows in advance how much time is necessary to remove the cancer and repair the wound, they ask that you make no other commitments for the entire day that you are scheduled for surgery.

Will the surgery leave a scar?
Yes.  Any form of treatment will leave a scar.  However, because Mohs surgery removes as little normal tissue as possible, scarring is minimized.  After the cancer is removed, the surgeon may choose 1) to allow the wound to heal by itself, 2) to repair the wound with stitches or a skin graft or flap, 3) send you to another surgeon for the wound repair.  Some Mohs surgeons do the closure the same day as the removal and some surgeons have you come back the following day for the closure.

Will I have pain or bruising after surgery?
Most patients do not complain of pain.  If there is any discomfort, Tylenol is all that is usually necessary for relief.  Avoid taking medications containing aspirin as they may cause bleeding.  You may have some bruising around the wound especially if the surgery is close to the eye.

Will my insurance cover the cost of surgery?
Most insurance policies cover the cost of Mohs surgery, however you should check with your carrier for exact information related to their schedule of payments.  On your visit plan to take your insurance card, photo ID.  If you have questions or difficulties understanding billing or payment policies contact our billing department.

Will I need to come back?
Usually only one or two return visits are needed to remove stitches or examine the healed surgical site.  Then, you may return to Dermatology & Advanced Skin Care for routine checkups.  After having one skin cancer, statistics show that you have a higher chance of developing a second skin cancer.

Risks of Mohs Surgery

Because each patient is unique, it is impossible to discuss all the possible complications and risks in this format.  The most common risks are summarized below.  We will discuss any additional potential problems associated with your particular case.  Please understand that these occurrences are the exception and not the rule.

Scars and Keloids: No treatment or surgeon should guarantee healing without a scar.  The size, shape, length, and visibility of the scar depend on the size, depth, and location of the tumor.  Keloids are scars that continue to enlarge after surgery and might require additional treatments.

Large defect: The defect created by the removal of the skin cancer may be larger than anticipated.  Typically, skin cancers are not much larger than what is visible to the human eye, but there is no way to accurately predict prior to the surgery.

Poor wound healing: Rarely, healing can be complicated and prolonged, especially lower extremities.  Incisions can reopen, and flaps and grafts can fail requiring the open wound to heal on its own.  Risk factors include diseases such as diabetes, poor physical condition, smoking, bleeding, and infection.

Infection: Rarely, wounds become infected and require treatment with oral or intravenous antibiotics.  Risk factors include the location of the tumor, diabetes and immunosuppression.  If you are at particular risk for infection, you may be given an antibiotic before or after the surgery.

Bleeding: There may be excessive bleeding or seeping postoperatively resulting in a collection of blood or lymph called a hematoma or seroma.  Such occurrences may require or produce reopening of the wound and prolonged healing. Strenuous activities within the first two days after surgery are the most common causes.  Other risk factors include certain medical conditions such as uncontrolled high blood pressure, medications such as ibuprofen or aspirin products, supplemental vitamin E, alcohol, garlic pills, and numerous herbal remedies.

Loss of motor (muscle) or sensory (feeling) nerve function: Rarely, the tumor invades or surrounds nerve fibers.  In such cases, the nerves must be removed along with the tumor. We will discuss any major nerves which might be near your tumor.  Some temporary numbness and tingling can result over any incision, especially flaps and grafts.

Loss of important structures: Tumors can involve vital structures such as eyelids, noses, ears and lips.  A portion of them may have to be removed with resulting cosmetic or functional deformities.

Tumor recurrence: Nor surgeon or treatment can guarantee a 100% cure rate.  Risk factors include immunosuppression, previously treated tumors and large, longstanding tumors.

Adverse reactions to medications: Rarely, a patient will have an adverse reaction to a medication or material used during or after the surgery.  Risk factors include a history of previous reaction or multiple chemical sensitivities.

How to Prepare for Mohs Surgery

Prior to your surgery:

• Read all of the information in this document. Let us know if you have any questions or concerns.
• Register on our patient portal. If you have not already created a patient portal account, please follow the directions on this website under Forms/Portal to register. You will need to register unless you created an account after 1/1/17. Once you have done this, you can provide us with your medical history by clicking on myVisits then Forms.
• Please take a photo of biopsy site with landmarks and bring with you.
• DO NOT STOP your blood thinners or aspirin if they are prescribed by your doctor.
• Blood pressure: Be sure that your blood pressure is controlled.  If your diastolic blood pressure (the lower number) is above 100 mmHg, we cannot safely perform the surgery.
• To change or cancel your appointment, please provide 48 hours notice or a $100 fee will be assessed.

We recommend that you stop the following products. If you do not, we will still be able to perform your surgery.

• Seven days prior to surgery we ask that you discontinue self prescribed blood thinners such as: Aspirin (Bufferin, Excedrin, etc), Ibuprofen products (Aleve, Advil, Motrin,etc), Vitamin E, Herbal remedies (garlic pills, fish oils, ginko, etc.)
• Four days prior to surgery, avoid alcohol-containing beverages (beer, wine, liquor, etc.) and alcohol-containing remedies (Nyquil, cough syrup, etc.)
• On the day of the surgery:
  • If prescribed, take your prophylactic antibiotics one hour prior to the appointment.
  • Have your usual meals.
  • Bring something to do such as a book, crossword puzzles, or a laptop.
  • Bring a drink, snack or lunch with you.  We are never sure how long the procedure will take.
  • Keep your schedule open because we do not know how many layers will be necessary. Most patients are in the office for three to four hours, but some patients require a full day.

After Surgery:

• Plan to keep the wound dressing that was applied in the office dry for 24 hours.
• Plan to relax the first two days.Plan to strictly avoid exercising, heavy lifting, and straining for two days.
• Plan to avoid motions that stretch the wound for the first four weeks.
• Plan to avoid pools and baths unless you apply a waterproof bandage and tape.
• Plan to avoid swimming in oceans, lakes, or streams until the sutures are removed.
• Plan to avoid hot tubs until the sutures are removed.
• Plan on being able to shower after the first 24 hours.

Problems after surgery are rare, but possible.  Please avoid planning trips within the first three weeks after the surgery so that we can manage any complications should they occur.

Aerlyn Dawn, M.D.

Dr. Dawn received his medical degree and many honors from Duke University, School of Medicine, Durham, NC in 2004. After completing his internship at the University of Maryland Medical Center and Mercy Medical Center, Baltimore, MD he trained in Dermatology at the University of Pennsylvania, Philadelphia, PA. He then completed his fellowship for Mohs Surgery and procedural dermatology at the Center for Dermatologic Surgery, Marlton, NJ.  Dr. Dawn is a member of the American Academy of Dermatology, American Society for Dermatologic Surgery, American Academy of Facial Plastic and Reconstructive Surgery, Pennsylvania Academy of Dermatology and Dermatologic Surgery, Women’s Dermatologic Society, Dermatology Foundation, The Skin Cancer Foundation. Dr. Dawn joined Dermatology & Advanced Skin Care in 2011.

Mohs Wound Care

To care for your surgical site, we recommend you have the following supplies on hand:

• Vaseline
• Non-stick (Telfa) dressing
• Micropore paper tape
• Cotton tip swabs

Change dressing daily by following the instructions below:

Bandaging & Cleaning:

• After 24 hours, you may remove the old dressing and shower.  We prefer you wait at least 24 hours to change your bandage.
• Use a cotton swab to gently cleanse the area with warm water.  This may take several swabs.  If a skin graft was performed, do not traumatize the graft site.
• If crusting is present and you cannot remove it easily, use warm soaks to soften the crust for 10 to 15 minutes, then follow the dressing instructions.
• Cut Telfa or nonstick dressing to fit the exact size of the stitches or wound.
• Apply Vaseline to the Telfa pad, then place over wound.
• Cover the Telfa with micropore tape (paper tape).
• Bandage must be airtight to promote faster wound healing.  If you cannot get it airtight, change it more often and reapply Vaseline.
• If the wound site is near the eye, use Lacri-lube instead of Vaseline, available over the counter at your pharmacy.

Applying Ice:

Keep your head or extremity elevated to decrease swelling.  Apply ice over your bandage 20 minutes out of every hour while you are awake and as much as possible in the first 24 hours after surgery.  Use a sealed baggy over a towel or a frozen bag of peas.  Icing over the wound will reduce swelling, bleeding, and pain.

Pain:

• Take extra strength Tylenol as directed for pain if necessary.  If a prescription pain medication was prescribed, please take as directed and avoid driving.  If you have severe pain that is not controlled by these medications, call the office (410-203-0607) during business hours or if it is after business hours, call Dr. Dawn directly on his cell phone (443-909-9041).
• Do NOT take any other over-the-counter pain medications such as Advil / ibuprofen or Aleve / naproxen because these can increase the risk of bleeding.

Bleeding:

If you experience bleeding around the surgical site, lie down and apply firm pressure to the surgical site for at least 15 to 20 minutes (as noted by your watch).  DO NOT discontinue pressure to see if the bleeding has stopped until at least 15 minutes has passed.  If the bleeding continues, it is likely that you are not putting enough pressure or the pressure is not in the right location.  If bleeding continues, call the office immediately (410-203-0607) during business hours.  If it is after business hours, call Dr. Dawn directly on his cell phone (443-909-9041). It may be necessary to go to the nearest emergency room.

Antibiotics:

Oral antibiotics are sometimes prescribed for wounds in certain locations or for complicated reconstructions.  If prescribed, take your antibiotic as directed until all pills are gone.

Healing Process:

It is normal to have some swelling, redness, and bruising around the surgical site.  Swelling is usually worst 2 to 3 days after surgery.  Swelling will gradually improve over one to two weeks.  Some clear or yellowish drainage from the wound may occur and sometimes has a foul odor.  Drainage usually decreases after a few days.  Please call the office at 410-203-0607 with any questions or concerns.

Exercise, Smoking, and Alcohol:

• Avoid any vigorous exercise for at least 48 hours after surgery.  Avoid strenuous lifting, stretching, straining or bending over during the first week after surgery.
• Do NOT drink alcohol for 48 hours after surgery.  Alcohol increases your risk of bleeding.
• Do NOT smoke during your healing after surgery.  Cigarette smoking constricts blood vessels, impairs wound healing, and can sometimes cause failure of the surgical reconstruction.

Follow Up Appointments:

• If you have sutures, an appointment should have been scheduled for you to have your stitches removed.  If you did not get an appointment, please call the office at 410-203-0607.
• Follow-up with Dr. Dawn as recommended to evaluate the surgical site or sooner if you have any concerns about how the site is healing.
• Schedule an appointment to see your regular dermatologist in 3 months for a routine exam.