If you’ve fished for any length of time, you’ve been exposed to the sun and if you hang around with hard core anglers you probably know someone who has been damaged by it. As I entered my fifties, I started hearing more of my friends and contemporaries talking about “Mohs” after their dermatologist visits. I was afraid to ask what that meant or how I’d know if I’d need it, too. Fortunately, we have a great resource in our friendly neighborhood dermatologist, Dr. Adam Tinklepaugh. Not only is he exceptionally skilled and highly-rated, but he’s also remarkably accessible. If you’re the type of person who is hesitant to go to the dermatologist because of what you might learn, he’s the doctor for you.
Here are his comprehensive yet easy-to-understand answers to my questions about Mohs surgery:
HPFC: What is Mohs surgery?
Mohs surgery is also called Mohs micrographic surgery and is named in honor of Dr. Frederic Mohs who created the procedure in 1936 in Wisconsin. Mohs surgery is only performed by dermatologists and is a type of surgery specifically for certain types of skin cancer that spares as much healthy skin as possible.
HPFC: How will my dermatologist know if I need it?
All board-certified dermatologists are trained to follow peer-reviewed guidelines regarding the treatment of skin cancer. Most dermatologists follow the Mohs surgery Appropriate Use Criteria (AUC) guidelines that determine which skin cancers should be treated with Mohs surgery.
HPFC: Does my dermatologist need special credentials or certifications to perform the procedure?
As a board-certified dermatologist and board-certified, fellowship-trained Mohs surgeon, I recommend that all patients ask their Mohs surgeon if they are a board-certified AND fellowship trained member of the American College of Mohs Surgery (ACMS). All members of the ACMS have spent at least one year after their dermatology residency completing highly selective surgical fellowship training where they complete at least 650 Mohs surgery procedures before practicing on their own.
HPFC: How worried should I be if I’m told that Mohs surgery is necessary?
You should be concerned about your diagnosis, but if you’re diagnosed by or referred to an ACMS member Mohs surgeon you should not be worried about your treatment. Your dermatologist and Mohs surgeon will thoroughly review everything to expect before, during, and after your Mohs surgery and you will have opportunities to ask questions and make informed decisions with your doctor.
HPFC: On which body parts is Mohs surgery typically needed?
Mohs surgery is typically reserved for skin cancers on the head, neck, hands, and feet, but there are certain instances when skin cancers on the arms, legs, and body are treated with Mohs surgery.
HPFC: Is Mohs surgery an outpatient procedure?
Mohs surgery is an outpatient procedure performed only by dermatologists in a clinic setting and under local, injectable anesthesia. General anesthesia is almost never required for Mohs surgery.
HPFC: Can my doctor perform it the day of diagnosis?
Skin cancers are typically diagnosed with a skin biopsy. A small sample of a skin lesion is sent to a dermatopathology lab which is interpreted by a pathologist. It typically takes up to one week to receive a final diagnosis and if you’re diagnosed with a skin cancer your doctor will contact you to discuss treatment options and to schedule a follow-up appointment. Mohs surgery can’t be performed without a definitive laboratory diagnosis, so it typically can’t be performed on the day of biopsy.
HPFC: What is the process? What tools are used?
Mohs surgery is a staged procedure, meaning it typically takes several attempts or “layers” to remove a skin cancer. This is because only the smallest amount of skin cancer-containing skin is removed with each layer so that your skin cancer surgery site remains as small as possible. Mohs surgery is a real surgery are requires the use of sterilized surgical instruments and machines that you would find in a hospital operating room.
HPFC: How long does it take?
Mohs surgery typically takes 2-4 hours to complete from start to finish. Each patient and each skin cancer are different, so Mohs surgery can take more time or less time depending on a variety of individual factors.
HPFC: Will there be anesthesia? Will it hurt?
Mohs surgery is typically performed under local, injectable anesthesia with an anesthetic medication called lidocaine. The injection of lidocaine feels like a pinch, but once the area is numb you should only feel pressure. Local anesthesia typically lasts for about 1-2 hours after surgery and your Mohs surgery site should be only minimally painful afterwards and for 2-3 days after your surgery. Pain medication is not typically required after Mohs surgery, but it’s always important to discuss pain control with your Mohs surgeon before and after your surgery.
HPFC: What sort of care is required afterward?
Woundcare is very important after Mohs surgery and your Mohs surgeon will review and provide woundcare instructions specifically for you. Typically, woundcare is very basic and includes gently washing your surgery site and applying ointments like Aquaphor or Vaseline with a bandage until your stitches are removed by your dermatologist.
HPFC: How do I care for the areas that have been affected after the procedure?
The woundcare recommended by your Mohs surgeon is the most important step immediately after your surgery. Also, if your Mohs surgery site is in an area that could be stretched or pulled, you should ask your Mohs surgeon how you should limit your activities. In the long-term, it is important to protect your Mohs surgery site from the sun’s rays because scars carry an increased risk of developing skin cancer.
HPFC: Will there be scarring?
Anytime the skin is cut it heals with scarring. Sometimes cuts are so small that we can barely see the scar once they’ve healed. All Mohs surgeries heal with scarring, but all board-certified, fellowship-trained ACMS member Mohs surgeons are extensively trained in skin reconstruction after Mohs surgery and perform more skin reconstruction after Mohs surgery than all other medical specialties combined. Mohs surgeons use techniques that will hide scarring in natural lines on the face and body and will result in the best appearing outcome.
HPFC: What is the likelihood of getting rid of the cancerous cells?
Mohs surgery has been extensively studied since it’s creation in 1936 and has consistently proven to be 99% effective at removing skin cancer. There is always the possibility that skin cancers return or that you develop a subsequent skin cancer, so we always recommend that if you have a personal history of skin cancer you should see your dermatologist at least once per year for skin cancer screening and a check of your Mohs surgery site.
Thanks to Dr. Tinklepaugh for helping us to better understand (and be less fearful) of this uncomfortable topic. Because skin care and sun protection are so critical for all of us, but anglers in particular, we hope to have him back with regular updates and columns. If you have particular questions, please shoot us an email so we can ask for his further assistance – and be sure to see your dermatologist regularly.
