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Mohs Surgery

Mohs is a technique for removal of skin cancers by a specially trained group of dermatologists (often called Mohs specialists or Mohs surgeons). The principle advantage of the Mohs technique is that the same physician that removes the skin cancer also subsequently examines the removed skin cancer and surrounding margin of normal skin under a microscope to make sure that the skin cancer has been completely removed. The patient is kept in the Mohs specialists' office and the wound is not repaired until the skin cancer has been completely removed. The Mohs specialist therefore acts as both the dermatologist and the pathologist. After successful removal of the skin cancer reconstructive surgery is performed to repair the hole (defect). Depending on a number factors such as patient preference, size and location of the defect, complexity of the defect, aesthetic expectations of the patient, and need for sedation, the resulting defect may be either repaired by a plastic surgeon or by the Mohs specialist.

Why is it called mohs?


Dr. Frederic E. Mohs
 

Dr. Frederic E. Mohs was a professor of surgery at the University of Wisconsin in the 1930s. He encountered a high incidence of skin cancer due to the large farming population. Dr. Mohs developed a technique for removal of skin cancers that has been refined over the ensuing decades but still credits his name.

The Mohs Technique

The Mohs technique allows for mapping of the removed tumor so that when a portion of the tumor is left behind, it can be seen under the microscope and it can be determined roughly where in the wound it is located. If the tumor was not completely removed the first time, more tissue is removed (this is called the second stage) and again subsequently examined until the skin cancer has been completely removed.


Mohs technique




First stage removes most of the skin cancer but a small portion is left behind





Examination under the microscope reveals that there is still skin cancer left behind in one of the quadrants and thus a second stage is performed to complete removal of the skin cancer

This process can take several stages and many hours to complete but offers the patient a very high (close to 97%) success rate in removal of the skin cancer as measured by lack of recurrence (meaning the skin cancer coming back in the same spot in a few years).

The dermatologist performing the Mohs procedure may also perform the reconstruction (plastic surgery repair) of the defect left after removal of the cancer. The decision of whether the Mohs specialist or a plastic surgeon performs the reconstruction depends on a number of factors:

  • Patient preference
  • Size of defect
  • Complexity of defect
  • Location of defect
  • Aesthetic expectations
  • Need for sedation

Plastic Surgery Repair after Mohs

If the patient desires repair by a plastic surgeon, the Mohs surgeon makes a referral to the plastic surgeon either before or after the skin cancer has been successfully removed. When a referral is made before the Mohs procedure, the patient and plastic surgeon have a chance to meet and discuss the reconstructive options. Also it allows enough time to schedule the reconstruction soon after the Mohs procedure to minimize the need for prolonged wound care for the patient.

Referrals to the plastic surgeon can also be made after completion of the Mohs procedure. This typically occurs because the skin cancer was larger than anticipated and the patient was left with a larger and more complex defect. It can also occur if the patient requests a plastic surgeon or is unable to tolerate the repair under local anesthesia.

Immediately after Mohs

This is an example of a patient just finishing Mohs removal of a basal cell carcinoma involving the tip of the nose. Because of her young age and high aesthetic expectations she was referred to Dr. Naficy for reconstruction. This is typical of a defect following Mohs removal of a basal cell cancer. It is located on the nose, which is the most common site on the face. It extends through the full thickness of the skin into the muscle layer of the nose. At times, removal of the basal cell carcinoma requires that a large portion of the cartilages of the nose also be removed.

 
Nose defect after Mohs surgery for a basal cell cancer

Immediately after Reconstruction

This patient underwent immediate reconstruction by Dr. Naficy using a complex technique involving two different skin flaps. This technique allows movement of skin from the side of the nose into the defect at the tip of the nose. The procedure was performed under IV sedation (with the patient sleeping but not under full general anesthesia). Meticulous suturing of the wound is performed to optimize the healing.

 
Following immediate reconstructive surgery by Sam Naficy, MD

Final Outcome

Despite the size and location of the defect and the amount of incision required to mobilize enough skin to repair the defect, the final cosmetic outcome was quite good. At times secondary procedures such as laser resurfacing or dermabrasion may be utilized to further enhance the cosmetic outcome after reconstruction of a Mohs defect.

 
Final outcome after reconstructive surgery by Sam Naficy, MD

Contact Us

If you are interested in pursuing Mohs surgery for your skin cancer you may contact us to schedule an appointment for plastic surgery evaluation. One of our nursing staff will contact you and conduct a phone interview to assess how we may best serve your specific needs. We can help you decide whether you are a suitable candidate for Mohs, whether you will require plastic surgery repair of your defect, and whether IV sedation anesthesia will be required. We will also review your skin cancer biopsy results and can expedite your referral to a qualified Mohs specialist.


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Naficy Plastic Surgery & Rejuvenation Center     1110 112th Ave NE Suite 150 Bellevue, WA 98004     (425) 450-0880