MOHS SURGERY

Our Mohs Surgeon

Dr. Pelster was born and raised in Brentwood, TN, a suburb of Nashville.  He completed his undergraduate education at Vanderbilt University, where he graduated as salutatorian of his class.  He remained at Vanderbilt University for medical school, where he received his medical degree and was inducted into the Alpha Omega Alpha honor society.

Dr. Pelster moved to Northwestern Memorial Hospital in Chicago, IL for his internship in Internal Medicine.  He remained at Northwestern University to complete a dermatology residency, where he served as a chief resident during his final two years.

Following residency, he completed an ACGME-accredited fellowship in Mohs micrographic surgery and dermatologic oncology under the direction of dermatologic surgeon Dr. Ian Maher at Saint Louis University in St. Louis, Missouri.  His mentor Dr. Maher sits on the board of the American College of Mohs Surgery and is internationally recognized as a reconstructive surgeon. Dr. Pelster also received extensive instruction in cosmetic dermatology, including the use of neurotoxins, injectable fillers, and laser devices.

Dr. Pelster has published multiple articles in various journals, including JAMA Oncology, Dermatologic Surgery, and JAAD Case Reports as well as several textbook chapters on dermatology and dermatologic surgery topics.  He has also served as an article reviewer for JAMA Oncology and Dermatologic Surgery.

He is a member of the American Academy of Dermatology, the American Society for Dermatologic Surgery, and the American Society for Laser Medicine and Surgery.

BOARD-CERTIFIED DERMATOLOGIST / FELLOWSHIP-TRAINED MOHS SURGEON
Ready to schedule an appointment?

What is Mohs surgery?

Mohs micrographic surgery is a specialized, advanced technique for the removal of skin cancer.  When compared to other forms of treatment, it has two important advantages.

  1. It has the highest cure rate for most skin cancers, up to 99% in some cases, as it allows evaluation of 100% of the deep and lateral margins under the microscope.
  2. It removes minimal normal healthy skin, thus improving your cosmetic outcome compared to other techniques.

Who is qualified to perform Mohs surgery?
The highest level of qualification for a Mohs surgeon involves completion of an internship (1 year), a dermatology residency (3 years), and an additional ACGME-accredited fellowship in Mohs micrographic surgery & dermatology oncology (1 year), which requires performing at least 400 cases as primary surgeon.  As there are some non-dermatologists and dermatologists without fellowship training that perform Mohs surgery, it is important to make sure that your Mohs surgeon is board-certified in dermatology by the American Board of Dermatology and that he or she has completed an ACGME-accredited fellowship.  Dr. Pelster is a board-certified dermatologist and completed over 900 cases as primary surgeon during his ACGME-accredited fellowship.

Does my skin cancer need Mohs surgery?

It depends.  In 2012, a large panel of physicians developed Appropriate Use Criteria (AUC) for the Mohs technique (Dermatol Surg. 2012 Oct;38(10):1582-603).  These criteria are generally followed with only occasional exceptions by most Mohs surgeons and insurance companies. Tumors on the scalp, face, neck, hands, groin, shins/calves, and feet frequently meet the criteria and benefit from Mohs surgery.  High-risk tumors in other sites (such as recurrent tumors, large tumors, tumors with aggressive features identified on initial biopsy, or tumors where the edges cannot be clearly defined) often meet criteria as well.  For small tumors on the trunk, arms, and legs above the knee, there is sometimes less benefit to Mohs surgery, and other treatments [standard surgical excision, “scrape and burn” (also known as ED&C), or topical chemotherapy creams] often make more sense.

Why do I need Mohs micrographic surgery?

For the reasons above, Mohs surgery is the treatment of choice for basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) of the scalp, face, neck, hands, groin, shins/calves, and feet.  Mohs is also useful for high-risk tumors (e.g. recurrent tumors, large tumors, tumors with aggressive features identified on initial biopsy, or tumors where the edges cannot be clearly defined) in other locations on the body.

My biopsy site seems to have healed up.  Do I really need another procedure?
Most likely, yes.  Biopsy itself uncommonly removes the entire tumor.  Often there is tumor left under the skin which is not visible; also frequently the lateral edges of a tumor are not visible to the naked eye and will continue to grow if not removed.

How do I prepare for Mohs surgery?

Do I need to bring a driver?
There are two instances in which you need to bring a driver:

  1. If the tumor is near the eye or upper part of the nose, often the post-operative pressure dressing will block the vision out of one eye, making driving unsafe.
  2. If you require anti-anxiety medications for surgery then you will need a driver also.  

If there is any concern or doubt in your mind, please bring a driver.

Can I eat the day of my surgery?

Yes, absolutely, please do.  Eat a hearty breakfast the morning of the surgery and take all of your usual morning medications.  We also recommend bringing a snack or small lunch, because sometimes you will be in the office until the afternoon.  In addition, because there can be a good amount of waiting time, it makes sense to bring a book, magazine, or computer/smart phone to pass the time.

Do I need to stop my blood thinners?
NO. Please continue all of your normal medications, including blood thinners.  Extra bleeding due to anticoagulant and antiplatelet medications can be easily managed during Mohs surgery, and the increased risk of a stroke, heart attack, or other clot from stopping these medications is not worth the risk.  Again, please continue all of your normal, medically-necessary medications.

Do I need an antibiotic?

Generally no, but it depends.  Patients with recent joint replacements or implanted devices (such as pacemakers and defibrillators) as well as patients at high risk for infection of the heart valves do sometimes benefit from antibiotics, and we can discuss this at your visit.  Additionally, some anatomic sites or large repairs also benefit from antibiotics.  This can also be discussed at your visit.

What happens during the procedure?

Step 1: The site of the tumor/biopsy site is marked with a surgical pen.

Step 2: The skin is cleaned and numbed with local anesthesia. Many patients have anxiety about the injection of the local numbing, but rest assured we use several techniques to minimize the pain associated with injection.

Step 3: The skin cancer is removed with a scalpel in a beveled fashion, taking narrow margins (generally 1-2mm, although this varies by location and the clinical situation). Prior to removal, reference nicks are made in the tissue and surrounding skin so that any remaining cancer can be precisely located.

Step 4: The removed tissue goes to the histology laboratory (on-site) for processing and the preparation of slides for the Mohs surgeon to review. Tissue processing can be time-consuming, so there is often a wait time of 1-2 hours while this is done.

Step 5: If there is any tumor remaining after review of the slides, this is precisely mapped so that the surgeon can remove only the necessary areas of skin, and then Steps 2-5 are repeated.

Step 6: Once the tumor is completely removed, the doctor will discuss with you your reconstruction options. .

Step 7: Reconstruction is completed on the same day in the majority of cases, and the wound is bandaged. The initial large, pressure bandage stays in place for 24-48 hours, after which you will perform daily wound care with petrolatum (Vaseline) and apply a much smaller dressing.

What should I expect during the recovery period?

Will I have a scar?

Yes.  A scar is the skin’s normal response to injury.  However, our goal for every patient is that—by 4-6 months after the surgery—the scar will not be apparent to a casual observer at normal conversational distance unless pointed out.  In his reconstructions, Dr. Pelster takes great pains to minimize scarring to ensure that the patient is just as beautiful after the procedure as he or she was before.  In addition, if these goals are not met, there are a variety of ways to improve scars later on, which can be performed in the office.  When you leave after surgery, we will also give you detailed information about the steps you can take to help with scarring, which include (after the area has had time to heal) wearing sunscreen, applying silicone gel products, and scar massage.

Why is the stitch line longer than the skin cancer?  

Most skin cancers are roughly circular in shape.  If a circle is stitched together directly, two unsightly lumps of tissue (called standing cones or “dog ears”) form at each end of the closure.  For optimal closure, a circular defect is converted into an ellipse (roughly the shape of a football) prior to straight-line closure.  The standard length of this ellipse is 3-4 times the length of the defect left by the skin cancer removal.  Although this can be startling when the bandage is first removed, a barely visible longer scar is much preferred to unsightly lumps of skin surrounding a shorter scar.

Why is my stitch line raised above the surrounding skin?

Most surgeons, including Dr. Pelster, believe in a concept called eversion.  In general, stitch lines that are raised above the level of a surrounding skin at the time of your procedure will leave a less noticeable scar in the long term compared to a stitch line that is entirely flush with adjacent skin.

What Comes Next After my Procedure?

Often, we will use dissolvable stitches.  If that is the case, we generally will schedule a follow-up appointment 12 weeks after the surgery to check in with you.  If non-dissolvable stitches are used, they will be removed in 5-14 days after the surgery depending on the location of the stitches.  Patients with non-dissolvable stitches will generally also have a follow-up appointment at 12 weeks as well.  Of course, if you have any concerns prior to that time, you are welcome to make an appointment to be seen earlier.

Please remember to carefully follow all of the instructions that we give you for care of the area after your appointment.

Subsequently, you should return back to the general dermatologist who referred you for regular full body skin checks, usually every 6-12 months (but sometimes more or less frequently at his or her discretion).  After one skin cancer, you have about a 2 in 5 chance of developing a second, unrelated skin cancer elsewhere on the body within the next five years.

SPECIAL OFFERS

Join our email list and be first to know about Advanced Dermatology’s latest treatments, events and cosmetic offers.

Newsletter Signup