Mohs Micrographic Surgery was developed in the 1930’s by Frederic E. Mohs, MD and is an effective means to treat various types of skin cancer. Typically the Mohs procedure is done in an outpatient setting under local anesthesia, so the patient is completely alert. Doctors specially trained in Mohs Micrographic Surgery first take as minimal amount of the skin as possible, and then analyze this tissue on the spot. They then determine if more cancerous tissue remains and, if so, repeat the process as necessary. For many skin cancers, Mohs surgery is an ideal way to minimize scarring, as only the exact amount of tissue is removed, no more and no less.
For some of us with larger or more rare skin cancers — like me – the Mohs procedure can mean a very long day at the doctor’s office and can result in quite a large wound. The positive outweighs the negative, however; the American College of Mohs Surgery (ACMS) website at http://www.mohscollege.org/ offers this encouraging information: “Because the physician is specially trained in surgery, pathology, and reconstruction, Mohs surgery has the highest success rate of all treatments for skin cancer – up to 99 percent. The Mohs technique is also the treatment of choice for cancers of the face and other sensitive areas as it relies on the accuracy of a microscopic surgical procedure to trace the edges of the cancer and ensure complete removal of all tumors down to the roots during the initial surgery.”
This article details my experience with the Mohs procedure. We all have different individual experiences with any type of medical procedure, so I don’t expect this article to represent Mohs surgery for everyone. I only hope to inform about my experience with Mohs, raise some issues you may not have considered, and perhaps offer some advice and reassurance.
I had no idea what a Mohs procedure was until I was diagnosed last year with Dermatofibrosarcoma Protuberans (also known as DFSP, which is much less of a mouthful). It begins in the dermis, or the second layer of skin. I described this full experience in a companion article on Associated Content at http://www.associatedcontent.com/article/773223/my_experience_with_dermatofibrosarcoma.html?cat=43. As I was writing that article, I hoped I would later be able to provide details about Mohs, which was the first of two surgeries I underwent to become cancer-free. After doing some research on my own, I was relieved that the Mohs procedure has become a chosen treatment for those with DFSP.
My primary concern was more about removing all of the cancerous cells than the scarring, even though the tumor was on my face. I had a tricky kind of tumor that was hard to diagnose, hard to fully remove, and typically sends out “roots” under the skin. Mohs seemed ideal.
My specially trained Mohs dermatologist had explained to me that the wound would be rather large, and would require separate reconstructive surgery with a plastic surgeon. This was scheduled for two weeks following the Mohs procedure. During those two weeks, I was to have a large, open wound on my face. The removed tissue would be tested further during that two-week period of time to ensure that all the cancer was gone. (This was necessary for the type of tumor that I had.) The Mohs dermatologist recommended that I stay close to home during that time. I thought that sounded like a fine idea.
My Mohs dermatologist also recommended that I take some sort of anti-anxiety medication the morning of the Mohs procedure to help me cope with the day. I am so thankful that I did take an Attivan, as it really decreased my worry and actually caused some amnestic effects, which was a nice side effect of the drug. (However, I did completely forget that I crushed my husband in a game of Scrabble…which he failed to reveal until it somehow came up in later conversation.)
The nurses numbed my cheek with a local anesthetic, and there is some pain involved in this process, but nothing unmanageable. The Mohs dermatologist then surgically removed an area of my skin. What you might want to prepare for is the fact that the actual surgery may take fifteen minutes, while the pathology of that tissue may take over an hour. So, I was left in the chair, encouraged not to get up and move about (especially due to the possible side effects of the Attivan). Fortunately my husband and father were able to come back into the room and spend that time with me.
We went through this process at least three times – numbing, surgery, and pathology. The Mohs dermatologist eventually reached my parotid (salivary) gland and could go no further. A circle of artificial skin was sewn over the wound because it was to be kept unrepaired for such a long period of time. By this point I believe it was about 4:30 p.m., and I had been there since 7 a.m. The entire Mohs procedure lasted a full day, but it seemed even longer.
Thankfully, the Mohs dermatologist was convinced that she had gotten all of the cancerous cells. She assured us that nothing unexpected would arise during that two-week period of further testing, and made a point to tell us that she had never had a “discordance” between the results of the Mohs procedure and the continued pathology following the Mohs procedure. Ultimately, she was wrong. She did, in fact, get all the cancer, but there were still atypical cells surrounding my parotid gland. Because of the likelihood that these cells would develop into a cancer recurrence, I opted for a superficial parotidectomy and reconstruction.
Even so, I have to adamantly say how grateful I am that the Mohs procedure exists, and that I was able to benefit from it. The Mohs dermatologist was surprised to find cancerous cells in an area on my cheek where no other signs of tumor were present. (In those areas I had never felt any sort of tumor on my face.) Without the Mohs technique, perhaps some of that cancer would have been missed.
Of course I eventually began to think of my appearance when I became more confident that the tumor was gone. Sadly, all of this destruction was happening on my face. The Mohs procedure probably saved a lot of tissue that would have been removed had I had “wide excision surgery,” another common treatment for Dermatofibrosarcoma Protuberans (DFSP).
In sum, here is some advice that I can give you about Mohs:
Make sure you are comfortable with your doctor and that your doctor has the right qualifications and experience to perform Mohs surgery. This website will help you find Mohs-trained doctors in your area: http://www.mohscollege.org/find/.
Make sure you have a clear idea of what your treatment plan will entail following the Mohs procedure. For instance, will you need stitches to close the wound or, in the case of a smaller wound, will it be left to heal on its own? Will reconstructive surgery be required, and how and when will it happen? Will your Mohs dermatologist repair the area or will you require a separate plastic surgeon?
If you think it is going to be a long day, take an Attivan (or other such drug). The Mohs procedure can be a grueling and anxiety-provoking process, so you might need a little help.
Bring along someone who: loves you, makes you laugh, can stomach an ugly wound, can ask questions of the doctor that you might forget while in this situation, and can remain patient. Actually, bring two others like this along, so they can keep each other company, too.
Bring your iPod. Woo hoo for the iPod “Mohs mix” I had all my friends and family make for me. It got me thinking of good memories with each of my loved ones. Of course, I could only listen to my music through one earphone because the Mohs surgery was on my face, but it was a great distraction.
Wear comfortable clothes. (Sounds like a no-brainer, but you really will appreciate being in sweats and furry slippers, I promise.)
Bring yourself some books, Sudoku puzzles, and travel Scrabble games to pass the time.
Be thankful – regardless of the needles, pain, time involved, and scarring – that the Mohs procedure exists. I am. Had I had this cancer one hundred years ago, the face I see in the mirror would not exist. Perhaps I wouldn’t exist.
My article on Dermatofibrosarcoma Protuberans (DFSP) generated a lot of positive and educational discussion in the comments section. I had hesitated in writing such a personal article on that topic, but ultimately felt pleased that it may have helped someone. Please feel free to share your comments here if you have personal experience with Mohs; your knowledge and questions can certainly help others preparing for their own Mohs surgery.