You have been referred to me for the removal of a skin cancer by a special technique called Mohs Micrographic Surgery. This is a complicated, time consuming technique and is therefore only used in special circumstances. The usual indications are for removal of a skin cancer that has recurred or has a greater potential for recurrence, or for removal of a skin cancer that is near an important structure where the sparing of as much normal skin as possible is desired. The procedure is done in our office under local anesthesia and can usually be accomplished in one day.

The actual technique involves several steps. First, the involved area is anesthetized with injections using a very small needle. This is the only painful part of the procedure and fortunately only lasts 1-2 minutes. The rest of the procedure should involve very little discomfort. Next, the bulk of the tumor is removed, and then a thin layer of surrounding tissue is removed surgically. The above steps usually take only 10-15 minutes. Next, the layer of skin that has been removed is processed and prepared for examination under the microscope. This is also done in our office. This tissue is carefully mapped and color-coded with dyes to enable me to determine the exact location of any residual cancer. The processed tissue is then carefully and systematically examined under the microscope. If any residual skin cancer is found, then the entire process is repeated, but only for the areas where residual tumor remains. The processing and microscopic examination takes approximately 1 hour. It is impossible to determine ahead of time how many times this process will need to be repeated.

We ask that you come to the office at your appointed time and expect to stay until 2-3 P.M. , but it does not always take that long. Please eat breakfast on the morning of the surgery as you will not be allowed to have anything further to eat until the procedure is completed. Take any medication that you may be on as usual, but avoid aspirin or aspirin-containing medications for at least 10 days prior to the surgery. Aspirin inhibits your blood's ability to clot and therefore may prolong bleeding during the surgery. We encourage you to bring a book or magazine with you, since most of your time will be spent waiting. We also insist that you have someone drive you home. If you so desire, someone can also wait with you during the time you are in the office. After the skin cancer has been removed, we will decide what to do about the wound created by the surgery.

Sometimes the wound can be allowed to heal by itself, which may take several weeks. Sometimes skin is removed from another area of the body and grafted onto the wound. Sometimes the wound can be closed directly with stitches, or some of the surrounding skin may be moved over (this is called a flap) and then the area closed with stitches. We will decide together what will be best for you after all the skin cancer has been removed.

You will be given written instructions after the surgery on how to care for the treated area. All wounds drain somewhat. Those that are allowed to heal without placing stitches drain more. Therefore, frequent bandage changes are necessary -- at least once a day. Mild bleeding can also occur following this type of surgery. If this should happen, apply direct, constant pressure without stopping for 20 minutes. You can expect some mild discomfort after the anesthetic wears off. Usually plain Tylenol is sufficient to control the pain. Do not take aspirin for one week following the surgery since this may promote bleeding. Swelling and bruising are quite common after this type of surgery and should resolve in 2-3 weeks. Skin cancers can often involve the nerves of the skin and it may take as long as a year or two until normal sensation returns. It is possible that the area may stay numb permanently. Also, the skin area that has been treated often feels tight. This tightness improves after several weeks to months. Anytime a skin cancer is treated, no matter what method, a scar always occurs. We will try to give you the best cosmetic result possible; however, the most important aspect is removing all of the tumor with the highest chance of it not recurring. Fortunately, scars tend to improve with time, but the maximum improvement may take as long as 1-2 years.

We will continue to see you periodically for the skin cancer treated in our office. However, you should see your own dermatologist regularly to check for any new skin cancers or for any other skin problem.

Yours Truly

David H. Friedman, M.D.
William R. Coleman, M.D.