Disease: Mohs Surgery

    What is Mohs micrographic surgery (MMS)?

    Mohs micrographic surgery is a special technique that uses local anesthesia (numbing) to remove skin cancers. The majority of cases are performed in the physician's office. Mohs is a very precise, highly detailed method whereby horizontal pieces of tissue are cut from the bottom-most layer layers of the tumor and immediately stained and examined under the microscope. Repeated saucer-shaped layers of tissue are removed and examined until no more skin cancer can be microscopically visualized in the sample.

    The procedure uses frozen sections of skin that are then stained with special dyes. The dyed frozen pieces of skin are examined under the microscope and a tumor map showing the sites of any residual cancer cells is drawn by the Mohs surgeon. The process allows an immediate examination of the entire tumor margin and tissue histology (microscopic examination of cells). If more cancer cells are seen under the microscope, then another skin layer is removed and again examined. Each skin layer that is removed is called a "level." If no more cancer cells are seen, then it is called "clear" (no more tumor) and no additional levels are needed.

    By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with excellent preservation of normal skin. Once the cancer has been fully removed, the Mohs surgeon looks at the wound to determine the type of repair for the best cosmetic result. Occasionally, the Mohs surgeon may refer patients to another physician to close the cancer-free wound.

    Mohs is special because the entire edge and under-surface of each skin cancer layer is carefully microscopically examined for the presence of cancer cells. Traditional surgical pathology techniques using standard sections (bread loafing), only is able to evaluate 1%-3% of the tumor margins thereby increasing the chances that a small tumor cluster might be missed and left behind. Mohs enables the examination of 100% of the entire tumor's margin thereby reducing the chance that tumor cells will be left behind.

    Mohs surgery is significantly more labor intensive than conventional methods of treating skin cancers and as a result it is more expensive. This type of surgery is typically reserved only for certain situations, which include recurrent cancers that have not been cured by conventional techniques, large tumors, tumors that occur in cosmetically sensitive areas like the mid-facial tissues, and so called morpheaform basal cell cancers which are known to have a high recurrence rate.

    Mohs is usually scheduled only on certain days in the doctor's office because of the required equipment, tissue stains (dye), and the presence of a histotechnologist for tissue processing. Most of these procedures are generally performed with the patient waiting in the office for the tissue to be "read" or interpreted by the Mohs surgeon.

    Why is the procedure called Mohs?

    Mohs is named after its inventor, Dr. Frederic Mohs, who first described the technique in 1941.

    Basal cell carcinoma on the neckSite after the tumor cells were clearedPost-op closure of the wound with sutures

    Where can I have Mohs Surgery, and how long does the surgery take?

    Mohs micrographic surgery is usually performed in an outpatient setting like a doctor's office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

    You are generally in the medical office for several hours on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctor's careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their day's schedule open to allow for adequate time to complete their Mohs procedures.

    What kind of physician can perform Mohs surgery? Where can I find a doctor board-certified in Mohs?

    Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or ear, nose, and throat (ENT) surgeons who are also trained to perform Mohs.

    There is no current board certification for Mohs surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery.

    This medical group has specialty training and certification exams for their members. Members of the American College of Mohs Surgery usually have completed an additional one to two years of Mohs training.

    Is Mohs only for skin cancer?

    Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers, including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove noncancerous growths. Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma, and other cancerous skin tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.

    Am I a good candidate for Mohs surgery?

    You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health.

    Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort with the procedure. Your physician can help you sort through the different treatments and assist in your shared decision-making process. However, the right decision for you is always yours and your doctor's to make.

    What if I have artificial joints or other health issues?

    Your Mohs surgeon needs to know of any underlying medical conditions that may affect your surgery or wound healing. You would want to be certain to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips, a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur.

    Your Mohs surgeon needs to know if you have had a history of staph or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like chlorhexidine (Hibiclens) the night or morning before surgery to help reduce the number of bacteria on your skin.

    Patients need to also advise their surgeon of any drug allergies to anesthetics like lidocaine (Xylocaine) or novocaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, hepatitis, HIV/AIDS, or pregnancy.

    Learn more about: Xylocaine

    What areas are treatable by Mohs surgery?

    Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, and ears.

    It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have regrown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

    What are possible complications of Mohs?

    As with any surgery or procedure, Mohs is associated with possible risks and complications. While it is overall a very safe and effective surgical treatment, there are some possible uncommon complications. Since a scar forms anytime you cut the skin, most patients understand and can expect some type of a scar after skin-cancer removal.

    Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid (raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, wound opening (dehiscence) and splitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and very rarely death.

    Minor, serious, or life-threatening reactions can occur with the use of anesthetics or with medications given before, after, or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent. Overall, most patients tolerate the surgery very well without any complications.

    What is reconstruction? Will I have a scar after Mohs surgery?

    Reconstruction is repairing or fixing the wound.

    Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometimes an area may heal best by letting the wound heal by itself naturally without stitches. Additional reconstruction options include using a skin graft or, moving a flap of skin.

    Shared decision-making is very important with this issue and it can help if you are involved by reviewing how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound.

    The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at options of how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

    When you cut the skin, there will be some type of scar. Some people heal easier than others. Some scars are more noticeable depending on the location and skin type.

    There are many options for treatment of surgical scars, including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. However, do not expect these treatments to completely remove the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch-removal appointment.

    Intra-op woundSutured woundHealed post-op site

    What are alternatives for Mohs surgery?

    It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, plastic surgery, curettage and desiccation (scrape and burn), regular excisional surgery, cryosurgery (deep freezing), and photodynamic therapy (uses a type of light and a light-activated chemical called a photosensitizer).

    You may decide to have regular surgery with a dermatologist or plastic surgeon instead of having Mohs.

    Alternatively, you may also choose a hybrid option, where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you.

    If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

    What about insurance coverage and costs of Mohs surgery?

    Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

    Mohs, like any surgical procedure, will result in additional procedure charges above the routine office-visit fees. These surgical fees may range from $1,000-$3,000 depending on the area, number of Mohs levels, and the type of closure or repair required. The greater the number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

    Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

    Commercial or non-Medicare insurances generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

    How do I prepare for my Mohs surgery?

    Your personal physician will let you know the preoperative instructions specific for your condition.

    Smoking is discouraged for at least one to two weeks before surgery. Smoking can slow wound healing and cause more wound infections.

    Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

    For many typical outpatient Mohs surgeries in a physician's office, most patients are advised to eat a good breakfast on the day of surgery and take all of their regular daily medications. Patients are advised to wear comfortable casual clothes and bring a sweater or small blanket.

    In most cases, patients are able to drive after most procedures and do not necessarily need a driver unless they feel uncomfortable. Diabetic patients may need to be more cautious about maintaining good blood sugars and avoiding dangerous lows in their sugars from fasting.

    Since you will be in the office for several hours, you may want to bring some personal snacks, drinks, and reading or knitting material. Personal music headsets or iPods may also provide relaxation and help pass time between Mohs levels.

    For surgery center or hospital-based procedures requiring any type of sedation or general anesthesia, patients may be required to not eat or drink anything past midnight the night before surgery. Your plastic surgeon or anesthesiologist will advise you of specific instructions before surgery.

    Most patients continue all doctor prescribed medications including aspirin and any blood-thinning medication unless specifically advised otherwise only by the primary physician or plastic or Mohs surgeon. Patients with a significant history of stroke, heart attacks, or even heart pain (angina) under a doctor's care must discuss their medications with their doctor before making any changes. It is important to not discontinue blood thinners without a doctor's specific instructions because of a potential greater risk of a heart attack and/or stroke.

    Learn more about: aspirin

    For otherwise healthy (non-cardiac and non-stroke patients) nonessential, nonmedically prescribed medications that thin the blood such as ibuprofen (Advil, Motrin), aspirin, vitamin E, garlic supplements, Alka-Seltzer, Pepto-Bismol, other aspirin-containing medications, etc., can be stopped at least seven to 14 days before undergoing Mohs surgery to minimize bleeding and bruising. These medications can thin your blood and make you more prone to bleed during and after surgery. Again, it is important to not discontinue or start any medication without a doctor's specific instruction.

    What is the recovery time for Mohs surgery? Is Mohs painful?

    Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is helpful.

    Stitches (sutures) are usually removed at the surgeon's office anywhere from four to 14 days from the date of surgery. Your physician will let you know what date to return for stitch removal.

    Most patients report minimal discomfort after surgery and require minimal or no pain medication.

    If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take acetaminophen (Tylenol) or another pain reliever over the counter. Aspirin or aspirin-containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain.

    Learn more about: Tylenol | Aspirin

    Your physician will let you know what pain medications are recommended for your specific condition.

    Most patients are able to return to work or school the next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for seven to 21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

    There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to skin cancer. Use of sunscreen or other cover-up on the scar is very helpful for at least six months after surgery to help minimize scarring. It is important to follow your own physician's instructions for wound care and sun protection.

    How do I take care of my surgical area after Mohs surgery?

    It is recommended to check with your surgeon for specific post surgery wound-care instructions. Often, you will be asked to go home and take it easy for the rest of the day. A few patients like to return to work and resume their work the day after surgery. It may be advisable to avoid heavy lifting and exercise, especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery. You will have usually have a bulky "pressure" dressing on the surgery area for one day. You may be asked to keep the area dry for 24 hours. Swimming pools, oceans, and Jacuzzis are usually not permitted while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide two to three times a day and applying petroleum jelly to the area. Mild swelling is not uncommon the first day or two after surgery and can be lessened by use of an ice-bag application, ice cubes or chips in a small Ziploc baggie, or frozen peas in the bag. Leaving the dressing in place, use cold pack application every five to 15 minutes every hour for the first eight to 24 hours after surgery. Swelling is more common for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area.

    The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to the site for 10-15 minutes may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified if bleeding persists. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding.

    Your surgeon will need to know if pain is increasing after one to two days after your surgery or if you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeon's office. The surgical area may need to be checked for bleeding or infection. Limiting hot foods, hot drinks, and heavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas. Your physician will explain recommended wound care.

    Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin-colored tape strips called Steri Strips are available to minimize wound leakage and help cover up a visible wound. It is important to follow your physician's instructions for wound care.

    Where can I have Mohs Surgery, and how long does the surgery take?

    Mohs micrographic surgery is usually performed in an outpatient setting like a doctor's office and under local anesthetic (lidocaine). Sometimes the procedure may be performed in an outpatient surgical center with the assistance of an anesthesiologist. Rarely, it is performed in an inpatient hospital setting.

    You are generally in the medical office for several hours on the day of your Mohs procedure. Depending on how large or difficult your skin cancer is, different numbers of levels may be required to achieve clearance. Mohs requires your patience and your doctor's careful effort and skill. It is not always possible to predict ahead of time how many hours your specific procedure will take. Most patients leave their day's schedule open to allow for adequate time to complete their Mohs procedures.

    What kind of physician can perform Mohs surgery? Where can I find a doctor board-certified in Mohs?

    Most Mohs surgeons are specially trained dermatologists. There are also some plastic surgery, or ear, nose, and throat (ENT) surgeons who are also trained to perform Mohs.

    There is no current board certification for Mohs surgery. There are two nationally recognized and respected national Mohs specialty groups called the American College of Mohs Surgery.

    This medical group has specialty training and certification exams for their members. Members of the American College of Mohs Surgery usually have completed an additional one to two years of Mohs training.

    Is Mohs only for skin cancer?

    Yes, Mohs is a widely used method of surgically removing the most common types of skin cancers, including basal cell carcinoma and squamous cell carcinoma. It is currently not used to remove noncancerous growths. Less frequently, Mohs may also be used for other malignant tumors. In special cases, Mohs may be used to surgically treat malignant melanoma, lentigo maligna, dermatofibrosarcoma protuberans, Merkel cell carcinoma, microcystic adnexal carcinoma, malignant trichoepithelioma, angiosarcoma, atypical fibroxanthoma, and other cancerous skin tumors. However, most Mohs surgeons treat primarily basal and squamous cell cancers by this technique.

    Am I a good candidate for Mohs surgery?

    You may not be a good candidate for Mohs if you are unable to tolerate local anesthesia, have extreme anxiety, have a surgical phobia, or are in very poor health.

    Your decision on the best treatment choice may depend on different factors such as the location and type of skin cancer, your past treatments, your overall health, and level of comfort with the procedure. Your physician can help you sort through the different treatments and assist in your shared decision-making process. However, the right decision for you is always yours and your doctor's to make.

    What if I have artificial joints or other health issues?

    Your Mohs surgeon needs to know of any underlying medical conditions that may affect your surgery or wound healing. You would want to be certain to tell your surgeon beforehand if you have any artificial parts (implants) like knees or hips, a pacemaker or defibrillator, or need to take antibiotics before dental procedures because of a heart condition or murmur.

    Your Mohs surgeon needs to know if you have had a history of staph or other skin infections in the recent past. You may be asked to wash with a special antibiotic soap or wash like chlorhexidine (Hibiclens) the night or morning before surgery to help reduce the number of bacteria on your skin.

    Patients need to also advise their surgeon of any drug allergies to anesthetics like lidocaine (Xylocaine) or novocaine. Additionally, the surgeon may need to know of any bleeding or bruising tendencies, hepatitis, HIV/AIDS, or pregnancy.

    Learn more about: Xylocaine

    What areas are treatable by Mohs surgery?

    Mohs is used primarily for the treatment of head and neck basal and squamous cell skin cancers. It is particularly useful for skin cancers in difficult areas such as nose, lips, and ears.

    It is also used on hands and feet where there is not a lot of extra tissue for bigger surgical removals. Mohs is very effective for the treatment of recurrent tumors (tumors that were previously removed and have regrown at the same site). However, depending on the specific patient and tumor type, any area of the body may be treated by Mohs surgery.

    What are possible complications of Mohs?

    As with any surgery or procedure, Mohs is associated with possible risks and complications. While it is overall a very safe and effective surgical treatment, there are some possible uncommon complications. Since a scar forms anytime you cut the skin, most patients understand and can expect some type of a scar after skin-cancer removal.

    Possible risks and complications of Mohs include (but are not limited to) bleeding, bruising, wound infection, pain, unsightly scar, keloid (raised, thick scar), cosmetic disfigurement, skin discoloration, nerve damage, allergic reactions, pain, reaction to local anesthesia, wound opening (dehiscence) and splitting or retained stitches, cancer recurrence, need for further surgery or treatment including radiation or plastic surgery, and very rarely death.

    Minor, serious, or life-threatening reactions can occur with the use of anesthetics or with medications given before, after, or during surgery. Nerves controlling muscle movement, sensation, or other functions may be damaged. This nerve damage may be permanent. Overall, most patients tolerate the surgery very well without any complications.

    What is reconstruction? Will I have a scar after Mohs surgery?

    Reconstruction is repairing or fixing the wound.

    Repairing or closing the wound may involve having your surgeon stitch the wound closed side by side. Sometimes an area may heal best by letting the wound heal by itself naturally without stitches. Additional reconstruction options include using a skin graft or, moving a flap of skin.

    Shared decision-making is very important with this issue and it can help if you are involved by reviewing how you prefer to repair the wound. Your Mohs surgeon may make some recommendations on how to close your wound.

    The main goal with Mohs surgery is to remove the skin cancer first. Once the cancer is cleared out, then your Mohs surgeon will look at options of how to best fix the area. The goal of Mohs is to clear skin cancer, achieve the smallest scar, and preserve normal tissue.

    When you cut the skin, there will be some type of scar. Some people heal easier than others. Some scars are more noticeable depending on the location and skin type.

    There are many options for treatment of surgical scars, including lasers, scar creams and gels, cortisone injections, and many other choices depending on the scar. However, do not expect these treatments to completely remove the scar. You may want to discuss ways to help minimize scarring with your doctor at your stitch-removal appointment.

    Intra-op woundSutured woundHealed post-op site

    What are alternatives for Mohs surgery?

    It is important to understand that there are alternative treatments and options to Mohs. Additional treatment choices include (but are not limited to) local radiation, plastic surgery, curettage and desiccation (scrape and burn), regular excisional surgery, cryosurgery (deep freezing), and photodynamic therapy (uses a type of light and a light-activated chemical called a photosensitizer).

    You may decide to have regular surgery with a dermatologist or plastic surgeon instead of having Mohs.

    Alternatively, you may also choose a hybrid option, where your Mohs surgeon removes the tumor and clears it for you and then you have the plastic surgeon fix up the wound and stitch it up for you.

    If you prefer to have your plastic surgeon repair the wound, you will want to let your plastic surgeon and dermatologist know ahead of time and plan that into your Mohs schedule.

    What about insurance coverage and costs of Mohs surgery?

    Mohs surgery is generally considered a medical service and is not considered cosmetic. Currently, most insurance plans cover the procedure under their provided benefits. However, with the many changes in insurance plans, it is always advisable to contact your insurance carrier prior to scheduling surgery and confirm your eligibility and benefits.

    Mohs, like any surgical procedure, will result in additional procedure charges above the routine office-visit fees. These surgical fees may range from $1,000-$3,000 depending on the area, number of Mohs levels, and the type of closure or repair required. The greater the number of levels required, the higher the cost. Surgical centers and hospitals usually have a much greater costs associated with a facility fee in addition to the surgery fee.

    Insurance benefits vary and reimbursement depends on what benefits you have contracted for with your company. Currently, Medicare generally covers 80% of Mohs cancer surgery. If you have a secondary insurance plan, that may help take care of the remainder 20% not covered by Medicare.

    Commercial or non-Medicare insurances generally cover a large percentage of your surgery unless you have to meet an out of pocket deductible first. You may want to get to know and understand your insurance benefits before having surgery. In many cases, you may also ask the billing office at the medical center or hospital for an approximate estimate of your charges before scheduling the procedure.

    How do I prepare for my Mohs surgery?

    Your personal physician will let you know the preoperative instructions specific for your condition.

    Smoking is discouraged for at least one to two weeks before surgery. Smoking can slow wound healing and cause more wound infections.

    Heavy alcohol use is not advised at least one week before surgery. Heavy alcohol use can cause more bleeding and thin your blood. An occasional glass of wine or small cocktail may not cause severe bleeding. Your physician will want to know of any factors that may affect your surgery or wound healing.

    For many typical outpatient Mohs surgeries in a physician's office, most patients are advised to eat a good breakfast on the day of surgery and take all of their regular daily medications. Patients are advised to wear comfortable casual clothes and bring a sweater or small blanket.

    In most cases, patients are able to drive after most procedures and do not necessarily need a driver unless they feel uncomfortable. Diabetic patients may need to be more cautious about maintaining good blood sugars and avoiding dangerous lows in their sugars from fasting.

    Since you will be in the office for several hours, you may want to bring some personal snacks, drinks, and reading or knitting material. Personal music headsets or iPods may also provide relaxation and help pass time between Mohs levels.

    For surgery center or hospital-based procedures requiring any type of sedation or general anesthesia, patients may be required to not eat or drink anything past midnight the night before surgery. Your plastic surgeon or anesthesiologist will advise you of specific instructions before surgery.

    Most patients continue all doctor prescribed medications including aspirin and any blood-thinning medication unless specifically advised otherwise only by the primary physician or plastic or Mohs surgeon. Patients with a significant history of stroke, heart attacks, or even heart pain (angina) under a doctor's care must discuss their medications with their doctor before making any changes. It is important to not discontinue blood thinners without a doctor's specific instructions because of a potential greater risk of a heart attack and/or stroke.

    Learn more about: aspirin

    For otherwise healthy (non-cardiac and non-stroke patients) nonessential, nonmedically prescribed medications that thin the blood such as ibuprofen (Advil, Motrin), aspirin, vitamin E, garlic supplements, Alka-Seltzer, Pepto-Bismol, other aspirin-containing medications, etc., can be stopped at least seven to 14 days before undergoing Mohs surgery to minimize bleeding and bruising. These medications can thin your blood and make you more prone to bleed during and after surgery. Again, it is important to not discontinue or start any medication without a doctor's specific instruction.

    What is the recovery time for Mohs surgery? Is Mohs painful?

    Recovery is usually very easy and uneventful. Overall, resting as much as possible the first few days after surgery is helpful.

    Stitches (sutures) are usually removed at the surgeon's office anywhere from four to 14 days from the date of surgery. Your physician will let you know what date to return for stitch removal.

    Most patients report minimal discomfort after surgery and require minimal or no pain medication.

    If there is pain, many patients find that they prefer to take something for pain at the first hint of discomfort instead of waiting until the pain builds up to an unbearable level. If you have mild or moderate pain, your doctor may advise you to take acetaminophen (Tylenol) or another pain reliever over the counter. Aspirin or aspirin-containing pain relievers may cause increased bleeding. Rarely, prescription pain medications may be required for severe pain.

    Learn more about: Tylenol | Aspirin

    Your physician will let you know what pain medications are recommended for your specific condition.

    Most patients are able to return to work or school the next day after Mohs. Avoiding heavy lifting, straining, or strenuous exercise for seven to 21 days may be required depending on the area of surgery. Your physician will need to let you know what activity precautions are required based on the area and size of your procedure.

    There are no specific strict sun restrictions after Mohs surgery. You may go out in the sun with sunscreen and protective hats and clothing. Overall, the sun is not your friend and should be avoided in excess. Excess sun exposure has been linked to skin cancer. Use of sunscreen or other cover-up on the scar is very helpful for at least six months after surgery to help minimize scarring. It is important to follow your own physician's instructions for wound care and sun protection.

    How do I take care of my surgical area after Mohs surgery?

    It is recommended to check with your surgeon for specific post surgery wound-care instructions. Often, you will be asked to go home and take it easy for the rest of the day. A few patients like to return to work and resume their work the day after surgery. It may be advisable to avoid heavy lifting and exercise, especially the first 24-48 hours after surgery. Your physician will usually give you more detailed instructions depending on the area and size of the surgery. You will have usually have a bulky "pressure" dressing on the surgery area for one day. You may be asked to keep the area dry for 24 hours. Swimming pools, oceans, and Jacuzzis are usually not permitted while the stitches are in. These may increase your chance of infection. Many physicians allow you to shower the next day after surgery. Wound care may require cleaning the wound with soap or hydrogen peroxide two to three times a day and applying petroleum jelly to the area. Mild swelling is not uncommon the first day or two after surgery and can be lessened by use of an ice-bag application, ice cubes or chips in a small Ziploc baggie, or frozen peas in the bag. Leaving the dressing in place, use cold pack application every five to 15 minutes every hour for the first eight to 24 hours after surgery. Swelling is more common for surgeries around the eyes or lips. Sleeping propped up on a few pillows or in a reclining chair may help decrease swelling after surgery of the head and face area.

    The surgical area may ooze a little blood or clear liquid especially in the first few hours after surgery; activity may aggravate this. Hot drinks or bending over at the waist can also initiate or worsen bleeding of face wounds. If bleeding occurs, firm pressure applied directly to the site for 10-15 minutes may be helpful. Most bleeding will stop if you apply enough pressure. Your surgeon should be notified if bleeding persists. Rarely, a visit to the hospital emergency room may be necessary for severe bleeding.

    Your surgeon will need to know if pain is increasing after one to two days after your surgery or if you are having fever or other concerning symptoms. In such cases, you may need to be seen at the surgeon's office. The surgical area may need to be checked for bleeding or infection. Limiting hot foods, hot drinks, and heavy chewing for 48 hours may help decrease the chances of postoperative bleeding for wounds around the mouth or cheek areas. Your physician will explain recommended wound care.

    Most patients are advised to try to avoid applying makeup or powder directly on a fresh wound unless the surface is fully healed. Skin-colored tape strips called Steri Strips are available to minimize wound leakage and help cover up a visible wound. It is important to follow your physician's instructions for wound care.

    Source: http://www.rxlist.com

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