- [Narrator] Welcome to Dartmouth-Hitchcock's
section of dermatology.
In the next few minutes, we will help explain Mohs surgery,
its advantages and risks, and what you can expect
before, during, and after the procedure.
Mohs micrographic surgery is offered
at three Dartmouth-Hitchcock clinics,
at the Heater Road facility in Lebanon, New Hampshire,
and in the Manchester, and Keene, New Hampshire clinics.
It is a highly specialized procedure
used to remove skin cancers
from the face, head, neck, and shins,
and for removing larger tumors
on the abdomen, legs, or arms.
- The primary application of Mohs surgery
is in the treatment of non-melanoma skin cancers.
Basal cell carcinomas, and squamous cell carcinomas
account for about 90% of those cancers.
- There are dozens of other types
of less common skin cancers out there
that are indications for Mohs surgery
but the majority of tumors
are basal cell and squamous cell carcinomas.
- [Faramarz] The advantage of Mohs surgery
is that it produces a smaller scar,
at the same time, the highest possible cure rate.
- For a basal cell carcinoma,
the cure rate is around 98 to 99%
for a primary basal cell tumor,
that's one that hasn't been operated on before,
and for a primary squamous cell carcinoma,
the cure rate is approximately 97 to 98%.
- The way it stands right now, if you don't do Mohs surgery,
the recurrence rate of those kinds
of very common tumors is quite high,
and you don't want that on the face.
- [Narrator] Mohs surgeons are trained
to understand how skin cancers appear and grow,
how they are removed,
and how they appear under a microscope.
They can determine the least amount of tissue to be removed
thereby reducing scarring
while efficiently removing the cancer.
- Skin cancer is interesting.
What we see on the skin, how large a lesion or tumors looks
on the skin may not be how large it is underneath the skin.
In other words, it may be bigger.
It may be twice as big under the skin than what we see.
- I tell patients that skin cancers are like trees,
and we can see the trunk and branches on the surface
much like we can see the surface of the tumor
on the surface of your skin but we can't see the roots
that are below the ground, or the roots,
or finger-like projections of some of these skin cancers
that are below the skin, so by doing Mohs surgery,
when we take a cut around the tumor,
and are visualizing it under the microscope,
I'm able to find the extensions of these tumors
under the deeper levels, or the dermal layer of the skin,
and follow them, and keep removing those sections
until they're all gone.
- [Narrator] If you have been scheduled for Mohs surgery,
try to get a good night's rest the night before,
and eat a good breakfast
before arriving for your appointment.
Take any of your prescribed medications
unless otherwise directed.
If you are taking aspirin for blood clotting,
or a heart condition, please continue to take it.
Otherwise, avoid any aspirin or aspirin-containing products
for 10 days prior to your surgery.
It is also important to avoid alcohol.
By the day of your surgery, your doctor will discuss
the things you need to prepare for recovery.
- During a preoperative consultation,
we review wound care instructions in detail.
We review the supplies that patients need,
and exactly what they can expect
in the postoperative period.
- Once the consent form is signed,
the patient is then prepped for surgery.
- [Nancy] Yes.
- [Lisa] You may come with me.
- All right.
- [Lisa] Good morning.
- [Lisa Voiceover] We bring them back to the room.
We go over their name, their date of birth.
- Nancy Smith.
- We do their vital signs.
We go over their history with them.
We go over their medications or allergies.
We get them into a hospital gown and a robe.
- [Robert] We also mark the spot with a surgical marker,
and have the patient confirm that that is in fact the spot
that we are treating that day.
- Do you agree that this is the correct spot?
- That's it.
- [Lisa Voiceover] We give them a warm blanket.
We have them positioned comfortably on the table.
- At bed time, a local numbing medication called Lidocaine
is injected into the site.
Lidocaine minimizes pain during skin surgery.
This allows us to take the first stage.
- [Narrator] During the Mohs surgery procedure,
the surgeon will first remove any skin cancer
that is visible to the naked eye.
This is typically done by cutting with a scalpel,
or scraping with a round blade called a curette.
Then to find out if the cancer has microscopic roots,
a thin ball-shaped layer of skin is cut from around the area
where the original visible cancer has been removed.
This sample is then taken to the lab for processing
by a technician called a histotechnologist.
- The ashes are 12, 3, 9 for orientation.
- All right.
- And I'll be in my office when you have a tissue or set.
- Okay. - Thank you.
- Thank you.
- [Faramarz] They freeze the tissue.
Subsequently they cut the tissue into very thin slices
that are placed in glass slides.
Tissue is then stained,
and then these slides are viewed utilizing a microscope.
- [Narrator] The surgeon reviews the slides,
and will be able to identify if any of the cancer
has spread beyond what was already removed.
While the skin is being processed in the lab,
and the surgeon review the samples,
the nurse will temporarily bandage over the wound,
and at that time, you can choose to stay in the room,
and take a nap, read a book, listen to music,
or return to the waiting area,
and visit with family or friends
who may have accompanied you.
- For a one-stage procedure,
it can take up to two hours,
however, from more complicated cases,
it can take up to three, four, even five hours
because it takes one hour for each stage to be completed.
- [Narrator] If the doctor sees additional cancer
under the microscope, he or she will mark its location
on a map of the original sample.
You will be brought back into the procedure room.
The temporary bandage is removed, and using the map,
the surgeon will then cut an additional margin of skin,
and send it back to the lab for further analysis.
The lab will prepare the new sample,
and the surgeon will again check for any additional cancer.
- I keep repeating that process till the tumor is all gone,
so the good news, again when the patient leaves the office,
they know that their tumor is gone that day.
Now once I come back in the room and say,
"Good news, cancer is all gone,"
there's typically a hole or surgical defect
from where we removed the cancer,
and we don't let people leave here
with a hole in their face or ear or nose.
We repair it for 'em that day.
- All wounds can heal on their own,
however, under certain conditions or settings,
it may be detrimental to allow the wound to heal on its own
in the sense that it could take longer to heal,
or it could result in a poorer cosmetic outcome,
or it could be associated with increased pain
during the healing process.
- And depending on the size of that surgical defect,
and how it affects other anatomic structures,
depends on how we close it.
- [Narrator] For smaller tumor removals,
the doctor will sew the skin together,
and only a fine line scar will result,
however, if the wound is larger, skin may be borrowed
from areas elsewhere on the body.
This is commonly known as skin grafting,
and also results in minimal scarring.
Minimizing scarring is one of the main advantages
of having Mohs micrographic surgery
as opposed to other types of skin cancer removal.
- If the wound is particularly large,
we then ask our plastic surgery colleagues
to lend us a hand.
Usually this takes place in the operating room,
and it usually occurs within a day or two
of the Mohs procedure.
- But this is rare, and most often unneeded, unrequired.
- [Faramarz] After the wound has been repaired,
we typically apply a pressure dressing
that stays on the wound for about 48 hours,
and the purpose of this dressing is to decrease swelling
at the operative site.
- [Narrator] Should you have any questions or concerns
during the postoperative period, you are encouraged
to call the dermatology office right away,
and either speak with a nurse, or schedule an appointment
in order to address those concerns.
- During the recovery period,
patients can experience some degree of pain,
which is usually relieved with Tylenol.
- The risk of Mohs surgery
is the same as with any other surgery.
There is no different than doing non-Mohs surgery
to remove a skin cancer.
There's always a bleeding risk.
There's 100% chance of a scar.
There are complications such as infection,
which are rare but do happen.
- For us at Dartmouth-Hitchcock,
risk of infection is less than 1%.
Similarly the risk of bleeding is quite low.
- Recurrence meaning the tumor coming back
to the same exact location, 1%, so this has a 99% cure rate.
There's very rare risks of nerve, artery, or tendon damage
depending on where you're operating
but those are much less than 1%.
- Often patients ask about how much pain
they're going to experience after surgery.
Surprisingly they typically experience very little pain,
and if they do experience pain,
this pain is generally well controlled with Tylenol.
- [Narrator] Dartmouth-Hitchcock performs approximately
1,000 to 1,500 cases of Mohs surgeries per year,
and it is performed five days a week.
For additional information,
you can visit dartmouth-hitchcock. Org,
and download the complete Mohs surgery guide.