Skin cancer is the most common malignant tumor in humans. Cancers are groups or clusters of abnormal cells which grow at uncontrollable and unpredictable rates. Although, the word “cancer” elicits a great deal of fear and anxiety, all forms of cancer are different. The three main types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Nonmelanoma skin cancer (basal cell carcinoma or squamous cell carcinoma) are the most common. These lesions are often red, scaly or waxy-looking and can be painful, bleed and increase in size. Some small or early basal or squamous cell carcinomas will be asymptomatic.
The most common type of skin cancer is basal cell carcinoma. This cancer rarely (less than 1% of the time) spreads or metastasizes to internal organs or other parts of the body. Because of this reason, basal cell carcinoma is only very rarely fatal. If left untreated, however, this type of skin cancer can destroy surrounding skin, invade deeply and damage underlying structures including nerves, bones, muscles, tendons.
Basal Cell Carcinoma/Squamous Cell Carcinoma
Squamous cell carcinoma is the second most common type of skin cancer. Compared with basal cell carcinoma, this cancer has a greater chance of spreading inside the body. The approximate metastatic rate is 1% for most squamous cell carcinomas. This risk , however, greatly increases for squamous cell carcinomas of the ear (~7% metastatic rate), lip (~15%), or those arising in scars (~25-30%). Like basal cell carcinoma, this cancer also frequently invades and destroys adjacent structures if not treated or incompletely removed.
Both basal and squamous cell carcinomas can be treated and cured by different methods. Mohs surgery is the one method that offers the highest cure rate (up to 99%), minimizes the potential for scarring, and is the most exact and precise means of removal.
This unique form of surgery was developed over 50 years ago by Dr. Frederick Mohs, a professor of surgery at the University of Wisconsin. Since that time, the technique has been refined and advanced so that today it is offered by Dermatologic Surgeons throughout the country.
Mohs surgery is a highly specialized form of surgery for the removal of skin cancer where the doctor acts as both pathologist and surgeon. In other techniques, such a frozen sections or standard excision, only a fraction of the margin (possibly only 1%) is examined under the microscope. By completely examining 100% of the margins of a tumor, and by mapping the extent of its growth, the Mohs Surgeon achieves much higher cure rates than other forms of treatment. Mohs surgery is performed on an outpatient basis under local anesthesia. Once the area is numbed, a thin layer of skin at the tumor site is removed. This layer is inked, frozen and stained so that it can be examined under a microscope. If any cancerous tissue is found at the edges of the first layer of skin, the doctor will repeat the process of removing another thin layer and preparing it for microscopic examination.
These steps will be repeated until the entire tumor is removed. Each layer of tissue that is taken is called a stage. Depending on the extent of the tumor, there may be several stages of surgery. Although some large cancers will require multiple stages, most basal and squamous cell carcinomas require only 1 or 2 stages for complete removal.
One of the major advantages of this technique is that the size of the surgical excision is greatly decreased; only the cancerous tissue and a tiny fraction of the surrounding skin is removed. This is particularly important if the cancer is close to important structures such as the nose, eyes, or ears. Of course any surgical procedure may leave a scar, but, by preserving the maximum amount of healthy skin, the size of the scar is minimized.
Once skin is free from the cancerous tissue, there are several ways of repairing the surgical site: to let it heal by itself, called “secondary intention healing”, to suture the wound together in a linear fashion, or to repair the area using a skin graft or flap. Skin grafts and flaps involve moving healthy skin from elsewhere to cover the defect. Once the cancer has been completely removed, and we know the size and shape of the defect, we will discuss with you the best options for repair in order to achieve the best cosmetic result.
What to Expect on the Day of Surgery
Eat breakfast normally as there is no need to fast prior to surgery. The time spent in most surgeries is usually fairly short (about 5-10 minutes to obtain the thin layer of skin and 15-45 minutes for suturing depending on the size of the final defect). The majority of the time in the office will be spent waiting for the microscopic results (about 45-60 minutes for each stage).
Since we cannot determine in advance how many stages you will require, you should plan to be at the office for most of the day. Rarely, it can take up to 8 hours to completely clear a site of cancerous tissue. In the majority of cases, however, the procedure will be finished and patients can return home within 3 to 4 hours.*
Post-Operative Care & Healing
You will be given complete post-operative instructions on the day of surgery. You will need antibiotic ointment and non-stick bandages, such as Telfa pads. Antibiotic ointments include Neosporin, Polysporin, Bacitracin and triple antibiotic ointment. These can be obtained over the counter. As some people are allergic to these medications, an alternative ointment is called Aquaphor. Postoperative pain is typically minimal and most people can return to work the following day.
Sutures are usually removed between 1 and 2 weeks. You can expect some degree of scarring as a result of this procedure. The initial scar, however, usually improves over several months and becomes more and more acceptable cosmetically. Scars that do not mature well can often be revised. Most revisions are done 12 months after the original surgery.*