Mohs Surgery: Treating Skin Cancer One Layer At A Time

Mohs Micrographic Surgery, Skin Cancer Treatment

Skin cancer is the abnormal growth of skin cells that develops in the epidermis or dermis. When mutations occur in the DNA of skin cells, this cause the skin cells to multiply rapidly and grow out of control, forming malignant tumours.

Most skin cancers are caused by ultraviolet (UV) light exposure, from the sun or tanning beds. If you have spent a lot of time in the sun or have a history of sunburn, there is a higher risk of developing skin cancer. The risk is also increased in individuals with a lighter skin tone – the lesser pigment or melanin you have in your skin, the lesser protection your cells have against UV rays.

As you age, you also tend to accumulate the exposure to UV radiation, which increases the risk factor for skin cancer.

Types of skin cancer

There are three major types of skin cancer — Basal Cell Carcinoma, Squamous Cell Carcinoma and Melanoma.

Basal Cell Carcinoma: They are abnormal, uncontrolled growths that develop from the basal cells in the skin’s outermost layer. They often develop on skin areas that are usually exposed to the sun such as ears, neck, face, limbs and shoulders. Basal Cell Carcinoma may appear as a flesh-coloured or pigmented lesion, or a recurring scabbing sore.

Squamous Cell Carcinoma: An uncontrolled growth of abnormal cells that arise from the squamous cells in the epidermal layer of the skin. They are common on sun-exposed body parts such as hands, neck and face. Squamous Cell Carcinoma may appear as a flat lesion with a scaly surface, or a firm, red nodule.

Melanoma: Develops from melanocytes, which are skin cells responsible for producing melanin pigment to give skin its colour. It can develop anywhere on the body, in an existing mole that turns cancerous or in otherwise normal skin, even in areas that are not exposed to the sun.

Other less common types of skin cancer include Sebaceous Gland Carcinoma, Merkel Cell Carcinoma, and Kaposi Sarcoma. Your treatment options depends on the type of skin cancer you have, and one that often stands out is Mohs surgery.

Mohs Micrographic Surgery

Mohs micrographic surgery is an advanced surgical technique of skin cancer removal that allows cancerous cells to be removed while preserving the surrounding healthy tissue. Also known as Mohs surgery, the procedure is named after the surgeon who developed the technique in the 1930s, Frederic E. Mohs.

This surgical approach offers the highest cure rates when treating a number of skin cancers including two of the most common types: Basal Cell Carcinoma and Squamous Cell Carcinoma¹. It is also suitable for skin cancers that have a high risk of recurrence.

A great advantage that Mohs surgery offers is allowing precise microscopic control of the entire tumour margin. Layers of the cancerous tissue are removed, one at a time, and examined microscopically to check for any remaining cancer cells until all cancer tissue has been removed.

This helps to maximise the conservation of healthy tissue, which is particularly useful in areas of aesthetic and functional importance like the eyes, nose, ears, hands and genitals. In addition, it also minimises the chance of regrowth especially for skin cancers that have a high risk of recurrence.

How the procedure is carried out?

The procedure will be done in stages all in one visit, and the patient waits in between each stage. The Mohs surgeon will remove the visible portion of the cancerous tumour along with a thin, underlying layer of tissue which will be examined under the microscope in an on-site lab.

Examination and prep: The surgical area will be cleaned and marked with a pen for reference. The patient will be awake for the entire surgery; an anesthetic will be injected into the area to numb it and make the procedure painless.

Top layer removal: The surgeon uses a scalpel to remove the tumour. Some skin cancers have roots or extensions that are not visible from the surface, so a layer of tissue surrounding the horizontal and deep edges of the tumour will be taken for lab analysis as well. The wound is bandaged temporarily while lab work begins.

Lab analysis: The tissue is cut into sections and colour-coded with dyes. The surgeon will draw a map of the surgical site. In the lab, the divided tissue is frozen and cut into thin horizontal slices and placed on the microscope slides for examination.

Microscopic examination: Under the microscope, the edges and underside of each tissue section is examined by the Mohs surgeon to assess for any evidence of remaining cancer.

Repeated layer removal: Based on the map, the surgeon returns to the patient in the operating room to remove another layer of skin where cancer cells remain. This process is repeated until there is no more evidence of cancer cells.

Wound repair: Depending on the wound size and location, it may be left open to heal or closed with stitches. In most cases, the surgeon will immediately repair the wound after obtaining clear margins. Sometimes, a skin graft may be needed or the wound requires reconstruction with a locoregional skin flap. Dr Angeline Yong who is trained in both Mohs Micrographic Surgery and cutaneous reconstruction will evaluate the final defect and discuss your reconstructive options with you before proceeding with the repair.

What happens after the surgery?

You may experience some discomfort, bleeding, swelling and redness after the procedure but these issues should go away on their own before long. Your doctor will provide instructions on how to clean and care for the wound, and any medication you need to take.

Mohs surgery provides the highest rate of recovery, but depending on your doctor’s recommendation, regular follow-ups may be scheduled to check your skin for new cancers. The usual period is twice a year, but your doctor may schedule them more often if the cancer is an aggressive type and is more likely to come back.

Am I a suitable candidate for Mohs surgery?

Mohs surgery has gained recognition to be the treatment of choice for Basal Cell Carcinomas and Squamous Cell Carcinomas, including skin cancer in areas around the nose, eyes, lips, ears and genitals.

It is also recommended if the skin cancer is large, aggressive or growing rapidly, has indistinct edges that are not well-defined, is of a high-risk subtype, and has recurred after previous treatment.

It is important to note that not every skin cancer patient is a suitable candidate for Mohs micrographic surgery as there may be certain characteristics of the tumour or its location whereby a different skin cancer treatment will be more suited. Your doctor will discuss the options with you and recommend the approach that offers the most optimal outcome.

Check and protect your skin

Early detection is crucial – most of the time, cases are curable if they are diagnosed and treated early enough. At home, learn to look at your own skin to notice any changes. Skin exams with a dermatologist are especially vital, for instance, mole checks can be carried out along with further testing to determine if you have skin cancer.

Be diligent about protecting your skin from the sun as much as possible. Wear sunscreen with at least SPF 30 and broad spectrum to cover both UVA and UVB rays. Apply generously and frequently to ensure full amount of protection from the UV light.

A complete assessment from a dermatologist and Mohs surgeon is crucial to help you select the right plan of management based on patient preferences and tumour characteristics. At Angeline Yong Dermatology, we provide a specialised full range of treatments for cancerous skin problems as well as benign skin growths.

Dr Angeline Yong is a dermatologist and dermatological surgeon who has a clinical interest in skin cancers, Mohs Micrographic Surgery and cutaneous reconstruction. She is also the first Singaporean to qualify as a member of the American College of Mohs Surgery, the leading body that accredits Mohs Micrographic Surgeons in the US. Prior to leaving for her private practice, Dr Yong was an integral member in the National Skin Centre’s skin cancer division and Mohs Micrographic Surgery service.

Contact our dermatology clinic to consult with Dr Yong regarding your skin health today!

Reference:
1. Prickett KA, Ramsey ML. Mohs Micrographic Surgery. [Updated 2020 Feb 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441833/

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Mohs Surgery: Treating Skin Cancer One Layer At A Time