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About Mohs Surgery

What is Mohs Surgery?

Mohs surgery is a specialized treatment for the removal of skin cancer. It is named in honor of the physician who developed the technique, Dr. Frederic Mohs. Mohs surgery is different from all other forms of skin cancer treatment. The difference comes from the use of a unique method for examining the surgically removed tissues, as well as detailed mapping techniques. These unique methods give the surgeon the best chance of removing every cancer cell.

By utilizing the unique methods mentioned above, a Mohs surgeon can locate cancerous areas that are not visible with the naked eye. Even the most miniscule grouping of cancer cells can be precisely removed using this method, which results in the greatest chance for total removal of the cancer cells. Mohs Surgery is most often used for large tumors, tumors near vital organs, tumors with indistinct borders, and those for which other forms of therapy have failed.

For most never-before-treated skin cancers, Mohs surgery can provide a higher than 97% chance for cure. The cure rate is around 95% for previously-treated skin cancers. Although Mohs surgery offers the highest rates of a cure, no surgeon or technique can guarantee a 100% chance of cure.

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Preparing for Mohs Surgery

When you go in for surgery, wear comfortable and loose-fitting clothing (no pullovers). If you get cold easily, you may wish to bring a sweater or jacket, as it is often kept cold in the office. If the area that you will be getting treated is on your face or neck, please do not wear makeup or jewelry.

We recommend that you eat a full breakfast on the morning of the surgery, as you may be in the office for most of the day.

Most patients should be able to drive themselves home after Mohs surgery. However, there may be some situations when it might be helpful to arrange for a ride to and from the office. For instance, if you would prefer to take an anti-anxiety medication on the morning of your surgery. It may also be more comfortable to have someone with you in the waiting room. Due to space limitations, we do ask that you only bring one other person with you on the day of your surgery.

We suggest taking Tylenol (acetaminophen) as prescribed about 30-60 minutes prior to your appointment to help minimize pain during surgery.

We will need your complete medical history, so if not complete prior to your arrival at our office, we will ask you to complete a medical history form. It can be helpful to bring a list of medications, allergies and past medical problems and treatments. We strongly suggest that you complete the online medical history form prior to your appointment. You can log on to our electronic medical records system  through the patient portal to complete the required intake forms. This will help with a more efficient intake process on the day of your surgery. Feel free to reach out to our office staff if you are having trouble completing the intake forms online.

On the day of surgery, you should take your normal medications as prescribed by your other doctors. For those that are on prescription or over-the-counter blood thinners, it is safe to continue use of those medications on the day of surgery. The side effects from stopping those medications is worse than the minimal increased risk of bleeding or bruising during or after surgery. Please feel free to contact our office if you have any questions about your medications.

Do not drink any alcoholic beverages for 48 hours prior to surgery and for 48 hours after surgery.

Day of Surgery

After your intake information is completed, our staff will show you to one of our surgical rooms. Photographs will be taken and written consent forms completed. You are encouraged to ask any questions that you might have at this time, prior to starting the procedure. Once your questions are answered, we will numb the area around the cancer and a thin layer of tissue around the cancer will be removed. The removed tissue is carefully examined, mapped, and color coded by the physician. It is then taken to the adjacent lab and in our office where a technician will process the tissue and make microscopic slides. This is done to allow for careful examination of the entire surgical margin. We will place a temporary dressing over the wound and you will return to the waiting area as we process the tissue.

The initial procedure takes anywhere from 15 – 20 minutes. However, it can take up to an hour and a half to prepare and examine the tissue (depending on the size and type of tissue, plus the type of cancer being treated). If a tumor is located during the examination, its location is established on the map and a thin layer of additional tissue is removed from the area. Multiple layers of tissue and additional examinations may be necessary. You will need to wait in the patient reception area between each stage of examination, which will each take around 90 minutes. There is no way to tell how many stages of examination are necessary, but most cancers are typically removed in no more than 3 stages.

In an effort to make your time with us as comfortable as possible, we encourage you to bring some reading material to occupy your time between examination and processing stages. We do have magazines available in the waiting area and Wi-Fi access is available as well for those wanting to bring laptops or other wireless devices. Depending on the amount of cancer that needs to be removed, you could stay with us past lunchtime, so feel free to bring a snack if you would like. The waiting area does have coffee, tea, water, and snacks available for your enjoyment. For most people, the most difficult part of the day with us is the uncertainty of when the procedure will be over. This is, unfortunately, impossible to predict ahead of time, so we ask that you plan to stay with us the full day that you are scheduled to be in our office.

After Surgery

Most patients that have Mohs surgery do not experience sever pain after surgery. There can be some mild to moderate discomfort for the first 12-24 hours that does occasionally require prescription pain medication. Dr. Pharis will prescribe these as necessary. Most patients can find relief through the use of over-the-counter acetaminophen (Tylenol). Avoid taking any anti-inflammatory medications such as Ibuprofen, Motrin, Aleve, Nuprin, Orudis, etc.) or aspirin-containing medications, as they could cause bleeding and excess swelling and bruising. Again, acetaminophen (Tylenol) is the only pain reliever that most patients require after the procedure. If you are unable to take acetaminophen (Tylenol), please let us know.

Yes, all forms of surgery leave a scar. However, since Mohs surgery removes the smallest amount of normal tissue possible, scarring is minimal. Once the cancer is removed, we will discuss with you the following options:

  1. Allowing the wound to heal by itself,
  2. Repairing the wound with stitches, or
  3. Reconstructing the wound with a graft or flap.

The decision is made on an individual basis, and only after all of the cancer has been removed so that the size of the wound is known.

For the best outcome, please follow the wound care guidelines as closely as possible. Your wound will require some care in the days and weeks following your surgery. The type of care that is necessary will depend on how the wound is managed on the day of the surgery. Verbal and written details on wound management and care will be provided, and you can always reach out to our office if you have any additional questions. [Wound Care Instructions]. You should plan to have the wound bandaged for at least one week, or sometimes longer depending on the location of the wound. You should plan on avoiding any physical activity like bending, straining, lifting, and most exercises during the first 2 days after surgery. You should arrange your schedule in advance in order to avoid these activities. Please reach out to our office immediately if you are having problems after surgery.

It does vary depending on the type of wound closure performed, but we typically ask that you return to the office 6-8 weeks after the surgery to check on how the wound is healing. We normally use dissolvable stitches to close the wound, so a suture removal appointment is not necessary. The importance of your follow up visit should not be underestimated. Results can be compromised if the follow up appointment is not kept. After ensuring that the wound has healed properly, you can return to your routine physician for normal checkups.

After one instance of skin cancer, statistics show that there is a much higher risk of developing skin cancer a second time. Your skin should be checked by a referring physician at least once a year, and in some cases, more often. These checkups are not only to examine the treated skin area, but also to check for new skin cancer developments. If you notice a new area that you suspect of being skin cancer, it is important to bring it to your physician’s attention as soon as possible.

The best protection from skin cancer is to avoid the harmful UV (ultraviolet) rays of the sun. Even if you tan easily, the sun can contribute to skin cancer in multiple ways. The first is that the sunlight damages the genes that control the growth of skin cells, and second, sunlight damages the body’s immune system so that early cancers can grow unchecked by the normal immune system.

Risks of Surgery

Since each person is different, it is not possible to discuss all potential complications and risks of Mohs surgery. There will be a scar at the site of the cancer removal. We will make all efforts to obtain optimal cosmetic results, but the primary goal of the surgeon is to remove the entire tumor. Typical results from Mohs surgery are discussed below, but it is important to know that these are essentially the same risks undertaken in any routine skin surgery. Dr. Pharis will discuss any additional potential problems associated with your particular case on the day of your surgery.

The risks listed below are the exception, not the rule:

  • The surgical wound created by removal of the skin cancer may be larger than anticipated. There is no way to predict prior to surgery the exact size of the final surgical wound. Also, the reconstructive surgery may be larger or more extensive than anticipated in order to avoid puckering or pulling on vital structures. Typically, a linear scar must be 3 times longer than the width of the surgical wound to avoid lumpiness or puckering of the scar.
  • Although all surgery leaves a scar, sometimes this scar can be thickened, spread, depressed or painful. At times this improves over time but if not attempts may be made to correct the problem.
  • Poor wound healing may occur, despite our best efforts. Many things influence how well you will heal (location of the tumor, bleeding, medications, poor physical condition, smoking, diabetes or other medical problems), Scars are typically thin fine lines, however. Occasionally they may be thickened, lumpy or they may spread or widen.
  • There may be loss of motor (muscle) or sensory (feeling) nerve function. Numbness is often temporary, but may occasionally be permanent. The lips and the scalp are areas where numbness is more common.
  • Although temporary swelling and bruising are common after surgery. Long lasting or permanent swelling is uncommon.
  • Some swelling resolves in days, while other swelling may take weeks or months to improve.
  • Rarely, wounds become infected and require antibiotic treatment. If you are at particular risk for infection, you may be given antibiotics prior to surgery or after completing surgery.
  • Smoking before or after surgery can lead to complications. Minimize smoking one week prior to and after surgery if at all possible, but it is best not to smoke at all during this time.
  • As a final thought, although the surgeon may perform your surgery in a standard fashion, and although you may follow directions for wound care perfectly, still in some cases, the body may not heal as both the doctor or the patient would hope, these uncommon cases cannot be predicted in advance. Although it is impossible to guarantee the results of surgery, Dr. Pharis will do everything possible to attempt to make you happy with your final appearance.
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