MOHS SURGERY

Kelly_M._Bickle,_M.D., performs Mohs Micrographic Surgery and runs the Mohs Surgery Center at Countryside Dermatology and Laser Center.  She is board certified in Dermatology and Dermatologic Surgery and completed a 12 month fellowship with Richard G. Bennett, M.D. of California in Mohs Micrographic Surgery.

Mohs surgery, named for Dr. Frederic Mohs who developed the technique, is a surgical method of removing and evaluating the margins of a skin cancer with frozen sections while the patient is in the office. Mohs Surgery allows the dermatologic surgeon to take smaller margins of tumor, obtain clear margins, and leave a smaller defect for repair.  This is most important if the tumors are large, unpredictable, and/or located on the lips, eyelids, nose, ears, hands, or genitalia.  Mohs Surgery has specific indications, and you will be scheduled for this procedure by your referring dermatolgist, or Drs. Bickle, Roper, or Moreland, if you are a candidate for Mohs Surgery.   Mohs Surgery is a very effective treatment for skin cancers, can be done in the office with local anesthesia and minimal discomfort, and is covered by Medicare and most insurance plans.

What is Skin Cancer?
There are many types of skin cancer: the three most common being basal cell carcinoma, squamous cell carcinoma and melanoma. Basal cell carcinoma is the most frequent type of skin cancer and although it does not usually go to other parts of the body, it can destroy adjacent structures and cause complete loss of the ear, nose, eyes, etc. Squamous cell carcinoma is the next most frequent type of cancer and has the potential to metastasize if located on the mouth, lips or genitalia, or if left untreated for several months.  However, treated Squamous Cell carcinomata rarely metastasize if removed early in the development process. Melanoma, on the other hand, has the ability to metastasize in the early stages. The frequency with which a melanoma spreads is usually correlated with the thickness of the tumor. While melanoma can metastasize to other parts of the body, it is usually curable when it is detected in the early stages, and treated.

When is Mohs Surgery Indicated?
Mohs surgery is useful in treating basal cell carcinomas and squamous cell carcinomas, melanomas, and some rare tumors, when these cancers are located on the nose , ears, lips, and eyelids. Mohs Surgery  may also be indicated for very large skin cancers, skin cancers that are long standing or that have recurred after previous treatment. Certain rare types of skin cancer, such as Merkel Cell, are also indications for performing Mohs Surgery. Finally, there are skin cancers with poorly defined borders that are best treated with Mohs surgery.

How is Mohs Performed?
Mohs surgery is performed in an office setting using local anesthetic. Tissue is removed and oriented with colored dyes. This color-coding allows Dr. Bickle to determine where the edges of the specimen are, and where residual tumor may be lurking.

After preparation in the laboratory, the periphery and underside of the specimen are evaluated. If cancer is seen at the margins of the specimen, more skin is removed from the patient at a site corresponding to the involved area. The tissue is again color coded and examined under the microscope. The process is repeated until no tumor is seen in any margin. This requires one to three stages in most cases, depending on the size and location of the tumor.

How Long Does the Procedure Take?
Although the time spent performing the surgery is only about 15 minutes per stage, each stage of Mohs surgery may take 1-2 hours, and if there are multiple stages, you may be at the office for four hours or longer. Most of this time is spent freezing the tissue and preparing slides. Tissue preparation takes between 30 and 60 minutes per stage.  It is  recommended that you bring a book, a sweater and a snack on the day of the surgery.   You will be spending most of the time in the Mohs Surgery waiting room , waiting for the tissue to be processed and told that the margins are clear.  If you are diabetic, bring any food you may want to eat, as well as your insulin if you need it during the day. 

What are the advantages of Mohs Surgery?
Mohs surgery offers many advantages in treating skin cancer. It allows Dr. Bickle to trace the cancer to its roots. This results in the removal of as little normal skin as possible while having the highest cure rate available.  The goal of Mohs Micrographic Surgery is to remove your skin cancer while preserving your normal healthy surrounding skin, in one visit.  The cure rate for Mohs surgery is very high, even for the most difficult tumors.  The cure rate is approximately 99 percent for new skin cancers and 95 percent for recurrent skin cancers (those which have been treated in the past and have come back.)  However, no one can guarantee a 100 percent cure rate with any treatment method.

Who performs Mohs Surgery?
Only dermatologists and a handful of plastic surgeons and ENT physicians across the United States perform Mohs surgery. The most highly trained Mohs surgeons have completed fellowships in Mohs surgery under the auspices of the American College of Mohs Surgery (ACMS).  Dr. Kelly Bickle is ACMS certified, as she did complete a very extensive fellowship in Mohs Surgery.  She is certified by the American College of Mohs Surgery to have the highest level of training in Mohs Surgery.

How should I prepare for Mohs Surgery?
Check with Dr. Bickle and her staff if you are on aspirin, coumadin, warfarin, or Plavix.  Avoid taking Vitamine E, Omega 3 fatty acids, billberry, flaxseed oil, and any extraneous herbs or vitamins you normally take. A multivitamin is not a problem, however.  Try to get a good nights rest and have a light breakfast before coming to the office.

What should I expect after the Surgery?
In many instances, Dr. Bickle, Dr. Roper, or Dr. Moreland , or your referring Dermatologist,  will be able to repair the defect from the Mohs Surgery skin cancer removal on the day of surgery (usually in the afternoon). In some cases, the repair is performed the following day, or Dr. Bickle will refer you to a plastic surgeon or eye surgeon for the repair to be done on a different day. Finally, there are some cases where letting the defect heal by itself will produce the least visible scar.

Most patients do not have significant discomfort following the procedure.  You will be given appropriate medication following the procedure for pain, and you can take it only if you need it.