Mohs Surgery is the Gold Standard for the Treatment of Nonmelanoma Skin Cancer
Mohs Surgery is an outpatient procedure that checks the entire margin of the tumor.
By Dr. Hayes B. Gladstone
Non melanoma skin cancers such as Basal Cell Carcinoma and Squamous Cell Carcinoma affect 1 in 5 Americans. It is an epidemic and a significant public health problem. The primary cause of nonmelanoma skin cancers is sun exposure. While these skin cancers have a low fatality rate, they can cause significant morbidity, disfigurement and decrease quality of life.
There are several types of treatments with varying effectiveness for nonmelanoma skin cancers. The treatments include; topical creams; cryotherapy; photodynamic therapy; electrodessication and curettage; wide surgical excision; mohs micrographic surgery; radiation therapy; oral medication.
Mohs Surgery is actually not a new procedure, having been developed 80 years ago by Frederic Mohs in Madison Wisconsin. It is outpatient surgery performed under local anesthesia. What distinguishes Mohs surgery from all other therapies is that it examines the entire surgical margin. The specimens are prepared in the office by a specially trained mohs histotechnician. The mohs surgeon then interprets the slides and microscopically maps the tumor. The definition of mohs surgery is that the surgeon also interprets these specially prepared slides. If there is still tumor present, then the mohs surgeon will take a small piece based on the precise map. Dermatologists have training to perform mohs surgery, though there is a highly competitive fellowship where fellows spend one year further developing and polishing these skills as well as reconstructing the defects.
In large, retrospective studies, mohs surgery has a cure rate of nearly 99% for first time basal cell cancer and 97% for first time squamous cell cancers. These cure rates are by far the highest for any therapy. Nonmelanoma skin cancers frequently go beyond what the eye can see—beyond the clinical margins—which makes the mohs surgery technique so important. Because of the precise microscopic mapping, mohs surgery will often remove less skin which may result in smaller scars. This is important in cosmetically sensitive areas. Mohs surgery is generally reserved for skin cancer on the head and neck, but may be used on the trunk and extremities if the tumor is large, or recurrent, or have very ill defined borders. The American College of Mohs Surgery, American Society of Dermatologic Surgery and the American Academy of Dermatology have developed Appropriate Use Criteria for Mohs Surgery.
When the skin cancer is completely removed by Mohs surgery, the mohs surgeon will often repair the defect the same day. Some defects will heal well naturally, but in many instances the mohs surgeon will need to put in sutures, either closing the wound in a line, using a flap or a skin graft. Dermatologists are trained to repair these wounds in residency and further develop and polish these skills in fellowship. One study showed that dermatologists repaired nearly 85% of mohs defects. There are instances where the defects are extensive enough and require general anesthesia when it will be necessary to have a general, facial or oculo plastic surgeon reconstruct the defect.
Removal of skin cancers is a process involving mohs surgery/reconstruction/optimization of the scar. Mohs surgeons are well versed in scar optimization from using topical therapies to dermabrasion to lasers.
Dr. Hayes B. Gladstone, is a fellowship trained Mohs and Reconstructive Surgeon and founder of the Gladstone Clinic in San Ramon and the former Director of Dermatologic Surgery at Stanford University. For more information, please call 925-837-6000 or visit www.GladstoneClinic.com.