Mohs Surgery in Houston, TX

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 and 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.

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. The biopsy itself uncommonly removes the entire tumor. Often, there is tumor left under the skin that 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.

Mohs surgery offers a wide number of advantages when performed at Advanced Dermatology in Houston, TX. A few of these benefits include:

• Precise microscopic control of the tumor during the procedure
• Effective and efficient results
• Useful for skin cancers with a high risk of recurrence
• Protects and conserves nearby healthy skin tissue

What restrictions will I have after the surgery? 

We recommend that patients avoid strenuous activity and exercise for two weeks following the surgery.  Lifting heavy objects (greater than 10 pounds) or otherwise stressing the surgical site dramatically increases the risk of a complication. 

Additionally, we recommend that patients do not expose the surgical site to water other than normal showers and baths for the four weeks following the surgery. Immersing the site in the Gulf, lakes, rivers, or even pools increases the risk of difficult-to-treat infections. 

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/smartphone 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 clots from stopping these medications are 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 the 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 reviewing 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.

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 a 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 includes (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, 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.

Often, we will use dissolvable stitches. If that is the case, we generally will schedule a follow-up appointment eight weeks after the surgery to check in with you. If non-dissolvable stitches are used, they will be removed in 5 – 21 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 eight 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.

As noted above, we recommend that patients avoid strenuous activity and exercise for two weeks following the surgery. Lifting heavy objects (greater than 10 pounds) or otherwise stressing the surgical site dramatically increases the risk of a complication.

Additionally, we recommend that patients do not expose the surgical site to water other than normal showers and baths for the four weeks following the surgery. Immersing the site in the Gulf, lakes, rivers, or even pools increases the risk of difficult-to-treat infections.

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 her or his 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.

What is MOHS surgery and why is it helpful?
MOHS surgery is a precise surgical technique utilized to treat various types of skin cancer. At Advanced Dermatology, our skilled surgeons employ this method as it allows them to remove cancerous tissue layer by layer, examining each layer until no cancer cells remain. This method ensures that the most healthy skin is preserved while effectively treating the cancer.

How does Advanced Dermatology ensure the success of MOHS surgery?
The success of MOHS surgery at Advanced Dermatology can be attributed to Dr. Au's expertise. He combines his experience with cutting-edge technology to meticulously remove and analyze each layer of skin affected by cancer. Patient care is paramount, and the team continuously updates their skills and knowledge to offer the best outcomes.

What can patients expect during their recovery after MOHS surgery?
After undergoing MOHS surgery at Advanced Dermatology, patients may experience some swelling, bruising, or discomfort around the treated area. It's crucial to follow post-operative instructions and keep the area clean to facilitate healing. Regular follow-ups with the doctor will ensure that the healing process is on track, and any concerns or complications are addressed promptly.

When facing a skin cancer diagnosis, it is crucial to do your research and find a trained Mohs surgeon who is a good fit for your expectations and needs. Success rates of the procedure are directly correlated to your doctor's skill and experience. To learn more about the experience, training, and personal success rates, call Advanced Dermatology now and simply schedule a consultation in Katy, League City, Pearland, or Sugar Land, TX.