Plastic Micrographic Surgery (Mohs Plus)

Mohs Micrographic Surgery

Under local anesthesia, a Mohs surgeon removes skin tumors one layer at a time, and the entire edge of that removed layer of tissue is immediately examined under a microscope.  The surgeon then removes additional tissue only in the area(s) where the margins are positive.  Those tissue sections are examined under a microscope and the process is repeated until all margins are clear of cancer.  These tumors often grow like roots of a tree, extending farther under normal-looking skin than what can be seen with the naked eye.  While most cases are cleared in one to three stages, larger or recurrent tumors often require multiple stages. Reconstructions requiring more than just a few stitches are performed in our state-of-the-art operating room, located within our suite. This facility was built to the strictest standards (AAAHC and Medicare) and provides the safest environment for reconstructive surgery.

Reconstruction

Dr. Piasecki has extensive training in reconstructive and cosmetic procedures and will perform the wound closure immediately after the tumor is completely removed.  Closing the wound during the same visit results in lower costs for the patient and the insurance company, and increased patient satisfaction because the patient avoids days or weeks with an open wound. 

Dr. Piasecki closes wounds with stitches, grafts or flaps and will present all the reconstructive options to the patient before deciding together which course to take.  Careful consideration of the functional as well as aesthetic requirements of the face are essential, and Dr. Piasecki helps patients weigh the desired cosmetic result with the recovery process.  Mohs surgery preserves the maximum amount of normal skin compared to other techniques, resulting in smaller defects and optimizing long-term appearance. 

Patients may continue taking their usual medications, even on the day of surgery, unless otherwise directed by a physician.  Patients are asked to inform Dr. Piasecki if they are taking any blood-thinning medications such as warfarin, Plavix, aspirin, ibuprofen, vitamin E or others.  Blood thinners can lead to increased bleeding, swelling and bruising following surgery.

Patients are instructed to get a good night’s rest and can eat normally prior to surgery.  Patients are also asked to bring healthy snacks and a sack lunch on the day of surgery.  Wearing comfortable clothing and an extra layer for warmth is also important.  A buttoned or zippered shirt that can be removed without going over the head is helpful.  Books, magazines or a laptop computer can help pass the time during the waiting periods of the day.  Patients should also arrange for a friend or family member to drive them home. 

Surgery begins with a consultation with Dr. Piasecki and a review of the informed consent form to ensure that Dr. Piasecki and the patient have a mutual understanding of the surgical process.  Once consent forms are signed and all questions are answered, the surgery begins. 

Click here for a copy of the Mohs surgery consent form to read and sign prior to surgery.

Local anesthesia is administered to the affected area.  Once the anesthesia has taken effect, the first level of tissue is removed.  The patient is then taken to the waiting room to relax while the tissue is processed.  This frozen tissue section processing and microscopic examination of the lesion requires 45 minutes to an hour.  During this time, the patient sits in the Mohs waiting room with friends or family, ample reading material or a laptop and plenty of food to snack on.  We provide beverages such as coffee, tea and water in this quiet, peaceful environment. 

If any of the cancer remains, the patient goes back to the operating room and another layer of tissue is removed in the area where the margin was positive.  The patient returns again to the waiting room to relax while the tissue is examined.  This process continues until the margins are clear of cancer.

The patient will then return to the operating room for a final time, and Dr. Piasecki will reconstruct the area using the plastic surgery technique that he and the patient agree is best tailored to the patient’s needs and will provide the most aesthetic result.

The tumor removal and reconstructive surgery typically occur in a single day, requiring approximately five to eight hours from beginning to end.  If the patient is scheduled for an 8:00 am or 8:45 am surgery start time, he or she should not expect to leave the clinic until approximately 2:00 to 4:00 pm.

Occasionally, complex cases require more time, many stages and/or delayed reconstructive repairs.  In such cases, Dr. Piasecki will discuss these issues, answer any questions or concerns and work with the patient to determine the best overall approach to treatment.

In nearly all cases, the skin cancer excision and reconstruction occur on the same day.  Most patients describe the pain following surgery as “throbbing” or “like a deep bruise”, but it is not typically sharp in nature.  Surgery on the forehead or scalp may trigger headaches on the first night or for the first few days of recovery.  Patients should take it easy for a week to ten days following surgery, with no heavy lifting (greater than a gallon of milk) or strenuous exercise. 

Depending on the size of the wound, “oozing” of fluid from the wound will occur for the first week or so following surgery.  Bruising, drainage of fluid and swelling will be at their peak at 72 hours following surgery, and occasionally this bleeding becomes heavier; if this happens, patients are asked to apply continuous pressure for 20 minutes.  If the bleeding persists, call Dr. Piasecki immediately to come into the clinic or a local emergency room.

Mohs surgery is a minimally invasive procedure and complications are rare, but they can happen.  Dr. Piasecki will discuss these with you the morning of surgery.

If you have any concerns following surgery, we ask that you call Dr. Piasecki during business hours at 253-858-5040 or after hours at 253-509-4438

A patient may be given antibiotics on the day of surgery and for a short period post-operatively.  In addition, a mild sedative (lorazepam) may be given if the patient feels anxious or the tumor is complex and requires prolonged removal and reconstruction time. 

Over-the-counter and/or prescription pain medications may also be prescribed to minimize discomfort.

As a Board Certified plastic surgeon, Dr. Piasecki can combine plastic micrographic surgery and cosmetic surgery. Patients often appreciate the convenience of combining minimally invasive procedures with plastic micrographic surgery and because you are already in our operating room, the rates for the cosmetic procedures are discounted.

Please contact our office to schedule a consult if you are interested in combining procedures. We will only do this if it won’t jeopardize your recovery for your skin cancer treatment and reserve the right to cancel the cosmetic portion of your surgery if the skin cancer turns out to be more invasive than expected.

Procedures that may be combined include:

• Mini facelift
• Necklift
• Eyelift
• Browlift
• Rhinoplasty (nose surgery)
• Otoplasty (ear surgery)
• Fillers and injectibles.