Preparation for Surgery:
On the evening before the surgery, you should prepare an envelope containing all the medical documents related to the surgery: the referral letter, the commitment from the health fund/financing authority, and the results of any laboratory tests requested for the preoperative examination.
It is advisable to have a good night's rest before the surgery and to have a nutritious breakfast on the morning of the procedure.
On the morning of the surgery, it is recommended to wash your face thoroughly, avoiding wetting the surgical area for three days after the procedure. If you regularly take medication based on a doctor's prescription, you should continue taking them as usual unless instructed otherwise. Patients treated with anticoagulants (e.g., Sintron, Coumadin) should consult with the doctor before the surgery. It is preferable to replace these medications with other anticoagulants with a shorter duration of action (such as Clexane). However, do not skip taking aspirin or medications containing aspirin before the surgery.
There is no restriction on taking Acamol (a pain reliever) at any time before the surgery.
Patients who know they are prone to anxiety due to the surgery are requested to inform the doctor in advance. In such cases, it is allowed and even recommended to take mild sedatives such as Clonazepam, Drops and Liam, Bach flower essence, and in more severe cases, prescribed medications such as Diazepam.
During the surgery, the patient will wear the clinic's pajama shirt to avoid soiling clothes in case of bleeding. You can also bring a comfortable old shirt from home that you don't mind getting stained.
It is advisable to bring reading material or any other means of entertainment to pass the waiting time as pleasantly as possible.
It is recommended to arrange for a companion who can stay with the patient and drive them back home after the surgery.
The Procedure:
A Mohs surgery is performed in three repeating stages:
The skin in the surgical area is anesthetized using local anesthesia. The visible growth is removed along with a thin layer of additional tissue beyond it. The removed tissue is photographed along with the surgical wound, creating a detailed map of the tissue and the wound - the Mohs map. This stage does not take a long time, and after it, the patient returns to the waiting room.
The excised tissue is marked and coded with colors to distinguish between the right and left sides and the upper and lower parts. The laboratory technician freezes the tissue and cuts thin "leaves" from it, representing the entire perimeter and deep borders of the excision. These "leaves" are placed on slides for microscopic staining. This stage is usually the longest and takes 40-60 minutes.
The pathologist examines the tissue sections under the microscope thoroughly. The entire surgical margin of the removed tissue is checked. Any remaining roots or growth bulbs, if present, are identified at this stage and their location is marked on the Mohs map. If the findings in the sections indicate the presence of residual growth beyond the removed tissue's borders, the surgeon uses the Mohs map to locate these remnants and remove them. The surgery continues with repeating stages 1-3 until the microscopic examination confirms that all the growth tissue has been removed. This method allows the Mohs surgery to leave the smallest possible surgical defect while completely removing the growth. The technique avoids unnecessary removal of healthy tissue and ensures that no remnants of the growth are left in the patient's body.
Duration of the Surgery:
In most cases, the surgery is completed in three stages or even fewer, and therefore it is expected to last up to 4 hours in total. However, it is not possible to predict in advance how extensive the growth is, as sometimes the roots are hidden within the skin and beneath it without any visible signs on the surface. Therefore, the surgery may take longer, and it is recommended that the patient allocate the entire day for the surgery and rest afterward.
It is essential to emphasize that the goal of the surgery is the complete removal of the growth. Achieving this goal may sometimes be associated with challenging outcomes from an aesthetic and functional perspective (damage to nerves, removal of vital structures for the sake of complete removal of the growth). If developments during the procedure may lead to such issues, the surgeon will stop and explain the situation and findings to the patient, and obtain approval to continue the surgery.
After the Surgery:
Once the growth has been completely removed, the surgeon will discuss the options with the patient, which may include:
Allowing the surgical wound to heal naturally without further surgery (often, such healing yields the best cosmetic result).
Performing a "plastic surgery" to correct and close the surgical wound immediately after the Mohs surgery.
Scheduling a delayed closure surgery of the wound a few days to weeks after the Mohs surgery.
Referral for further treatment in a different department within the hospital (plastic surgery, ENT, oral and maxillofacial surgery) based on the findings during the surgery.
Conclusion of the Surgery:
At the end of the surgery, the appropriate dressing will be applied, consisting of special plasters only or dressing with gauze and antibiotic ointment. Hair-bearing areas such as the scalp/beard/lips may require dressing with a special foam instead of plasters. Depending on the surgery's duration, location, and the surgeon's evaluation of the risk of secondary infection in the immediate period after the surgery, antibiotic treatment may be prescribed for 7-10 days after the surgery.
Pain, Swelling, or Bruising After the Surgery:
Most patients do not complain of significant pain after the surgery. In case of discomfort or pain, significant relief can usually be achieved with common pain relievers such as Acamol/Ophtalgine/Neurufin. If necessary, the doctor may prescribe stronger medications for pain relief. Bruising (subcutaneous bleeding) and swelling may occur after the surgery, especially when the surgery is performed near the eyes (forehead, cheeks, nose).
Removal of Stitches:
In most cases, the stitches will be removed by the surgeon between 7-10 days after the surgery. After the removal of stitches, further dressing may be required for a few days to one week until complete healing of the surgical wound. In some cases, the surgeon may recommend the use of silicone gel for massaging the surgical scar to improve and accelerate the healing process.
Surgical Scar:
Every surgery leaves a scar, but Mohs surgery minimizes the scar to the greatest possible extent compared to other methods by removing only the necessary cancerous tissue. The surgeon uses special plastic surgery techniques to achieve the best results.
In the first few months, the scar will be reddish, and it will only become clearer over time. The appearance of the scar will continue to improve during the first year. Exposure to sunlight may cause the scar to develop a different color from the surrounding normal skin, so it is recommended to avoid sun exposure during the first year. Scars may remain reddish, thick, or raised (hypertrophic or keloid scars) even for an extended period after the surgery. These outcomes are primarily related to the body's healing abilities. In such cases, the surgeon may consider intervening to improve the healing, which may include injecting steroids into the scar, massaging with silicone gel, and even surgery to correct the scar.