The tissue is processed in the Mohs method to allow the pathologist to examine the margins and allow the surgeon to “trace” the roots. Unlike classic Mohs, which is processed in one day, skin cancers like melanoma have to be sent to an off-site lab for processing. The pathology result typically returns anywhere from 2 days to 1 week later. If the margins are positive, another sample of tissue in the affected area will be removed and the process will be repeated until the margins are clear. You’ll return to the office for the results, more tissue sampling (if needed) and reconstructive surgery with Dr. Rausch.
Why do I need a large margin of normal tissue to be taken around the melanoma? The tumor and some normal tissue around it (margin) will be removed surgically. This procedure reduces the chance that cancer cells will be left in the area. The width and depth of surrounding skin that needs to be removed depends on the thickness of the melanoma and how deeply it has invaded the skin. The margin typically is 0.5cm to 1cm circumferentially around the tumor. The size of the excision margins is important because wider margins might lead to a greater chance of surviving the melanoma but at the expense of worse cosmetic results or adverse effects from the more extensive surgery. Slow Mohs can limit the margin in some instances where the tumor is in a critical location. With slow Mohs, the roots of the tumor can be tracked to increase the chance of clearance.
Using Slow Mohs surgery, the percentage of cure is more than 99% for most skin cancers and 95% when other previous forms of treatment have failed. Other methods of treatment offer cure rates that are significantly lower than Slow Mohs surgery.
What to Expect
Please arrive at our office at the specific time assigned to you. This is a surgery appointment and different than a regular office visit. Your actual surgery time will be roughly one hour after you arrive. The physician needs to thoroughly review your case and your surgical suite needs to be prepped. Surgery is usually scheduled later in the afternoon.
Our staff will escort you into an exam room where Dr. Rausch will discuss your case with you and further explain the procedure. A local anesthetic is injected into the skin to numb the area to be treated. Once the area is numb, the cancer is removed as well as a layer of tissue around the cancer. The procedure takes about 15 minutes. A pressure dressing is applied to the area where the cancer was removed. You’ll be sent home with an open wound. Verbal and written wound care instructions will be given to you after surgery.
Pre-operative Consultation: Consultations with Dr. Rausch are done the day of surgery but can be arranged prior to surgery if desired. If you’re uncertain about surgery because you are considering another form of treatment or no treatment at all, please call before your scheduled surgery date to avoid a cancellation fee.
Biopsy Site Identification: Smaller cancers are difficult to identify. You must be able to identify your biopsy site the day of surgery. It’s helpful to take a photo of your biopsy site before it heals. Bring the photo with you the day of surgery or email to firstname.lastname@example.org (photos you send may not be encrypted).
Medications: Continue all medications prescribed by your doctor, including blood thinners, aspirin, Coumadin, Plavix, Vitamin E and blood pressure medications. Studies show discontinuation of prescribed medications, even for short periods, can put one at risk for life threatening events, such as heart attack and stroke.
Food and Drink: Since surgery is performed under local anesthesia, you may eat and drink that day.
Alcohol: Alcohol promotes bleeding. We ask you to avoid alcoholic beverages 48 hours before and after surgery.
Smoking: Smoking can affect healing by diminishing blood supply at your surgery site. Discontinue smoking 2 days before surgery and for 1 week after surgery. If you can’t discontinue entirely, cut back to less than 1 pack per day.
Transportation: Make arrangements for someone to drive you the day of surgery. Patients given medicine to relieve anxiety will not be allowed to drive themselves home.
Attire: Wear comfortable, older clothes, avoid make-up, perfume and jewelry. If surgery is on an area covered by clothing, wear something easy to remove.
Cancellations: If you must cancel surgery, please cancel 48 business hours before your surgery date. Less than 48 business hours notice will result in a cancellation fee.
Please don’t travel outside the area for 1 week so that any post-operative issues can be addressed. If you have any problems at home after surgery, please do not hesitate to call our office. Verbal and written instructions for wound care will be given to you at the end of your day.
Will I have pain and bruising after surgery? The surgical site may be sore for several days. Tylenol and Ibuprofen are usually adequate for relief. Bruising and swelling are common and may not peak until 48 hours after surgery. Do not plan surgery around an event where your physical appearance is important as you’ll be wearing a bandage for a week in most cases.
Will I be able to return to work or be able to drive? If you’re given medications during surgery, you will not be allowed to drive yourself home. Returning to work or driving will depend on the size and location of your cancer/abnormal lesion and your occupation. Please bring all FMLA paperwork with you the day of surgery. In most cases, time of work will not be granted after surgery. Specific restrictions will be discussed the day of surgery. If you would like to discuss this prior to surgery so arrangements can be made ahead of time, a consult is required.
Can I exercise after surgery? Activities, including exercise or heavy lifting, will be restricted until stitches are removed. The more activity you participate in, the more likely you may bleed from the surgery site.
Will the surgery leave a scar? Whenever surgery is performed, there will be a scar. Dr. Rausch is trained in advanced reconstruction and fine suturing techniques to optimize the cosmetic outcome.
Will I need to come back? Suture removal and wound evaluation are usually performed one week after reconstructive surgery, which will not be done until the pathologist determines that all the cancer is removed. In some cases, visits may be needed over the next several weeks to months. Periodic visits at least once a year to your referring physician are advisable to monitor for skin cancers or signs of recurrence.
What is melanoma? It’s the most serious form of skin cancer and originates from melanocytes, the cells which produce the pigment melanin that colors our skin, hair and eyes. The majority of melanomas are black or brown, but can be skin colored or pink.
What causes melanoma? Sunlight is the main environmental agent. Research shows other risk factors include dysplastic moles, more than 50 ordinary moles,fair skin, freckling, personal or family history of melanoma or other skin cancers, weakened immune system (organ transplant or HIV), history of severe/blistering sunburns, excessive sun exposure or tanning bed use. Still, many get this disease with no known risk factors.
Why should melanoma be treated? Melanomas are curable if recognized and treated early. If not, the cancer can advance and spread to other parts of the body, where it becomes hard to treat and can be fatal.
What treatments are used for melanoma? Surgical removal offers the best chance for a cure. For melanomas thicker than 1.0mm, lymph nodes near the tumor may be removed because cancer can spread through the lymphatic system. If the pathologist finds cancer cells in the lymph nodes, it may mean the disease has already spread to other parts of the body. Doing sentinel lymph node biopsies has not shown any overall survival benefit. It does provide more information about your prognosis. Therapy may be given after surgery to kill cancer cells that remain in the body. This treatment is called adjuvant biological therapy. If the tumor has spread to other parts of the body, other methods such as chemotherapy, biological therapy, radiation therapy, or a combination of these methods may be used.
How can I protect myself in the future? A previous melanoma puts you at an increased risk for developing future melanomas. Early detection is critical. Studies show that people who perform skin self-exams have thinner, less advanced melanomas. Early detection can reduce mortality by as much as 63%. Regular total body skin exams by your physician are essential. You should minimize sun exposure and avoid tanning beds -- studies show a 75% increase in melanoma risk when indoor tanning began before age 30.