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Mohs Micrographic Surgery as a Skin Cancer Therapy

Aaron S. Cetner, M.D., F.A.A.D.
Aaron S. Cetner, M.D., F.A.A.D.
Leonard Y. Kerwin, M.D., F.A.A.D.
Leonard Y. Kerwin, M.D., F.A.A.D.
Mohs Micrographic Surgery is an advanced treatment process for skin cancer that offers the highest possible cure rate for many skin cancers and simultaneously minimizes the sacrifice of normal tissue. This cutting-edge treatment requires highly specialized physicians that serve as surgeon, pathologist and reconstructive surgeon.
The microscopic analysis of resected tissue allows the surgeon to track the removal of the cancer and ensure the complete elimination of all tumor roots. As tumors often extend below intact normal skin (like the roots of a tree) this procedure allows the surgeon to see beyond the visible tumor to ensure its complete removal.
The technique is most often used to remove the two most common forms of skin cancer: basal cell carcinoma and squamous cell carcinoma.
The cure rates for Mohs Micrographic Surgery approach 99% for most primary (untreated) cancers with a slightly lower cure rate for secondary or recurrent (previously treated) cancers. While limiting the sacrifice of uninvolved tissue, this specialized procedure preserves the greatest amount of normal tissue. This benefit of the procedure provides the foundation for the best reconstructions and limits scarring or permanent disfigurement. Mohs Micrographic Surgery remains the most effective method of removing non-melanoma skin cancer (basal cell cancer, squamous cell cancer, sebaceous carcinoma, Extramammary Paget's disease, Dermatofibrosarcoma protuberans, etc.) available anywhere in the world today.
The Center for Skin Surgery is located at our Novi location. Dr. Aaron Cetner, M.D. and Dr. Leonard Kerwin are Board Certified Dermatologists and both have completed Fellowships in Mohs Surgery.

Mohs Surgery

Drs. Aaron Cetner and Leonard Kerwin are specialists in skin cancer surgery, with a special focus on the Mohs surgery technique. Their expertise includes the treatment of basal and squamous cell carcinoma, malignant melanoma, and other rare skin tumors.
Mohs micrographic surgery remains the gold-standard treatment for basal and squamous cell carcinoma, offering the highest potential cure rate for these cancers. Although not required for the treatment of every cancer, Mohs surgery may be the best choice in many cases, and also allow for the best cosmetic result.
Mohs micrographic surgery is best performed by a doctor with specialized training and extensive experience. Mohs surgeons complete a one-year fellowship certified by the American College of Mohs Surgery (ACMS). Since that time, he has performed thousands of Mohs procedures, while also performing same-day aesthetic repair on over 99 percent of these cases. You can be confident in our talented and highly trained surgeons' ability to achieve excellent results.

Why Mohs?

There are many available therapies for skin cancer. In many cases, treatments such as freezing, burning, radiation, or simple excision are appropriate. However, for tumors that are aggressive or located in cosmetically sensitive areas, these treatment methods may not be successful, as they rely on the naked eye to determine how much of the skin is affected. This may increase the chance of recurrence or cause unnecessary scarring.
With Mohs surgery, your surgeon removes the visible tumor with a small margin (called a "stage" or "layer") and then examines this tissue under a microscope to map out the extent of the cancer. If tumor remains, this process is repeated until the physician is ensured that all of the cancer is removed. This process of mapping out the "roots" of the cancer minimizes the risk of the cancer recurring, spares healthy tissue, and leaves as little scarring as possible.
Mohs surgery is indicated for basal and squamous cell carcinomas in certain situations, including:
  • Cancers located in cosmetically sensitive areas of the face, ears, neck, and scalp
  • Cancers located in areas where sparing normal tissue is critical, such as the hands, feet, or lower legs
  • Cancers that are large, aggressive or growing rapidly
  • Cancers where the borders are difficult to define with the naked eye
  • Cancers that have come back (recurred) after previous treatment

Preparing for your Mohs surgery

Mohs surgery is performed on an outpatient basis under local anesthesia. You will not have to go to the hospital, and will not be "put under" with general anesthesia. Each "layer" or "stage" of Mohs surgery can require up to an hour to sample, process, and examine the tissue. The length of your surgery can therefore range from a few hours to the entire day, depending on the ultimate size and complexity of your skin cancer. It is a good idea to bring a book or magazine to occupy your time, though televisions are available in all of our surgical suites. Reconstruction typically takes place immediately following clearance of the tumor, after which you will be able to go home.
It is important to prepare properly for your Mohs surgery. We recommend eating breakfast and taking all of your regular medications the morning of surgery. Unless directed by your physician, please do not take aspirin, ibuprofen (Motrin, Advil), Naproxen (Aleve), Vitamin E, or Gingko Biloba for one week prior to surgery, as they may increase the risk of bleeding. Alcohol may similarly increase the bleeding risk, and should be stopped one week prior to and after surgery. Cigarette smoking can impair healing, and should be stopped or significantly reduced for at least one week prior to and after surgery.

What to expect after surgery

After your cancer has been completely removed, he will determine the best method to repair the wound. Wounds are occasionally allowed to heal on their own, but more often are repaired with stitches. This may be done in a simple straight-line fashion, or may require a skin flap or skin graft. It is rarely necessary to consult other surgical specialists and arrange reconstruction on another day.
All wounds are initially dressed with a bulky pressure bandage that must be kept dry and intact for 2 days. Thereafter, once daily wound care is continued until the stitches are removed (usually 7 to 14 days after surgery).
Your physical activity will be limited for at least a week after surgery (and up to two weeks for some surgical sites). Activities such as heavy lifting, running, and working out must be avoided. Please make appropriate arrangements for work.
Most patients have minimal discomfort after surgery, and we recommend over-the-counter Tylenol (Acetaminophen) or occasionally Ibuprofen for pain.
Swelling and bruising are variable depending on the individual and surgical site. If surgery is done in close proximity to the eyes, lower forehead, or upper nose, some bruising and swollen eyelids should be anticipated.
There will be a scar at the site where the cancer is removed. The scar begins to heal in 1 to 3 weeks, but continued healing and improvement in the appearance of the scar occurs over the first 6 months. While the size of the scar will depend on the extent of the cancer, every effort is made to make the surgical site as inconspicuous as possible.

Frequently Asked Questions

Should I arrive earlier than my scheduled appointment time?
Yes. 15 to 30 minutes ahead of your scheduled time is advised in order to complete the registration process.
What papers should I bring with me?
A list of your medications
Insurance card(s) and Medicare card (if applicable)
Photo ID
How long will my procedure take?
It is not possible for us to estimate this at the outset. You may be here for as little as two hours, or you might be at the office for the entire day. For this reason, we advise patients to not schedule any other appointments or engagements the day of surgery.
Why?
Although most skin cancers are cleared in one or two stages of Mohs surgery, it is impossible to predict those that will require more stages. Similarly, certain locations may require a more complex, and thus more time-consuming, reconstruction.
May I have breakfast and take my medicine(s) before surgery?
Yes, please do (especially if you are a diabetic)
What type of anesthesia will I have?
We use only local anesthesia. No general anesthesia or IV sedation is used.
Should I have a driver?
You must have someone drive if your skin cancer is around/near your eye.
The dressing you wear home may block your vision.
What if the skin cancer isn't near my eye?
It is up to you if you want a friend/family member to do the driving. However, it is always a good idea to have someone to call if the need arises.
I am very anxious about the procedure? Do you have medicine to help me relax?
Yes, we are able to administer oral Ativan (Lorazepam) on the day of surgery. However, you MUST have a driver in order to use this medication.
Is it true that smoking increases the likelihood of complications following surgery?
Yes, smoking does impair wound healing. Although we do not expect patients to quit smoking, decreasing the amount smoked (ideally to less than one pack per day) for seven days before and after surgery is recommended.
I am on oxygen. Do you have oxygen available if I run out?
We have oxygen if there is an emergency only. It is your responsibility to have enough oxygen available for the duration of the day.
Should I stop taking any medicines?
There are many non-prescription (over the counter) medicines that thin the blood. Please stop these 7 days before surgery. Ibuprofen-containing products such as Advil or Motrin, Aleve (naproxen) Vitamin E (a multi-vitamin that contains Vitamin E is permissible) Ginseng, Ginger, Ginko Biloba, Alcoholic beverages (please also refrain from alcohol use for 7 days after surgery).
What should I take if I have a headache/muscle or joint aches?
You may take Tylenol if needed.
I am taking Aspirin. Should I stop this?
Please check with your prescribing doctor to see if this can be discontinued. In general, if you are taking Aspirin for primary prevention only (e.g. you have never had a heart attack, stroke, blood clot, etc), then you may discontinue it. If you are taking Aspirin for a medical condition, you must check with your prescribing doctor prior to discontinuation.
My doctor has me on Coumadin. Should I stop this?
No. Continue to take this as prescribed. However, we do recommend that you check with the prescribing/monitoring physician to make sure your blood is within the therapeutic level. This should be done within the two week period prior to your surgery.
Should I stop Plavix? (or other blood-thinning medication such as Aggrenox or Pradaxa)
In general, we do not discontinue these medications prior to surgery. These medications should only be stopped if the prescribing physician directs you to stop them prior to surgery.
I have had a joint replacement procedure in the past. Do I need antibiotics prior to surgery?
In general, if your joint surgery was performed in the past year, pre-operative antibiotics are required. If your joint surgery was performed over a year ago, they are not required. Please contact the office to obtain a prescription prior to surgery if appropriate.
Do you have a coffee machine?
We do not have a machine available to patients, but one of our staff can make you a cup.
Is it okay to bring food with me?
Yes. You may be here at lunchtime so bring a sack lunch with you. You may also bring snacks to have on hand during the course of the day. We highly encourage you to bring something to snack on.
Can I leave the office to grab a bite to eat or a cup of coffee?
If time permits, you may be able to go out for something. Please inform the staff if you desire to leave the building.
What kind of bandage will I be leaving with?
You will go home with a bulky dressing over the surgical site(s) that we ask you to leave on for 48 hours.
Can I go to work the day after my surgery?
This depends on the recommendation of the doctor. We are happy to provide a work excuse if necessary.
Can I workout, run, play sports, or do heavy lifting after surgery?
No. We ask you to refrain from strenuous activities for at least 1 week after surgery (and often 2 weeks, depending on the site). This is critical to minimize complications and bleeding, and to ensure optimal healing.
My skin cancer is on my lower leg. Will I be able to walk around after surgery?
Due to tension on lower leg surgical sites, we recommend that you are off of your feet as much as possible following surgery. Walking for necessities is permissible, but extended distance walking for pleasure (e.g. exercise, hiking, a trip to New York) is not recommended for two weeks following surgery.
Will I be bruised or have any swelling?
Yes. Although this varies considerably among patients, assume that you will have bruising and swelling for a week or longer. The site of surgery as well as your activity level contributes to the amount of bruising and/or swelling you may have.
Will I need to do any wound care to the surgical site(s)?
Yes. A detailed wound care sheet will be sent home with you.
If you have additional questions, please do not hesitate to contact our office at: 248-773-3640