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Cost Of Mohs Surgery Vs Excision

Younger People Benefit Too

How to Take Care of Your Excision or Mohs Surgery Site

The number of people who develop skin cancer has been increasing for decades, and, alarmingly, more women and men under age 40 are now being diagnosed with the disease. Particularly in women, indoor tanning has been linked by many experts to an increased incidence of skin cancers at younger ages.

In my practice, I treat at least one patient in his or her 30s each week with Mohs surgery and many in their 40s and 50s, which is vastly different than 20 years ago, when the majority of patients were older. Not many young people seriously worry about getting skin cancer. Many use tanning beds and skip sun protection, and if they discover an unusual growth on their skin, they often delay seeking treatment because they think its no big deal. But it can be. Basal cell carcinomas rarely metastasize, or spread through the body, but some have aggressive growth patterns and can cause significant damage by growing along nerves or blood vessels, or through muscle or bone. By allowing the cancer to grow, you risk requiring more extensive surgery in the future. Squamous cell carcinomas can be more dangerous, carrying an approximately 4 percent risk of metastasis and 2 percent risk of death6, and the risk increases when these cancers return after treatment.

Arielle N.B. Kauvar, MD

Are You Awake For Mohs Surgery

Yes, most people are awake for Mohs surgery. Your surgeon will numb the area with injected medications . You will feel pressure and touch but no pain, and youll rest comfortably in the waiting room or in the operating room while they analyze your tissue. If you need more skin removed, you may still be numb from the initial injections, or more injections may be needed.

What if Im anxious about surgery?

Its quite common to feel anxious before a procedure. Your healthcare provider may recommend a variety of techniques to calm your nerves. During the procedure, you may want to listen to music or a guided meditation. Your provider may also give you antianxiety medication before the procedure.

Will Mohs Surgery Work For Everyone And Every Tumor

We follow appropriate use guidelines for Mohs surgery, as we would for any treatment. In 2012, a study outlined the criteria for appropriate uses of Mohs surgery. This is an evolving document and will soon be updated. In general, Mohs is deemed appropriate for:

  • Head and neck tumors
  • Tumors on areas that needed tissue sparing such as the hands, feet, genitalia, and shins
  • Tumors with an aggressive histologic appearance
  • Tumors greater than two centimeters off the head and neck
  • Tumors on immunosuppressed patients, including those with organ transplants, leukemias/lymphomas, autoimmune conditions, and on immunosuppressive medications

The decision to perform Mohs surgery is ultimately a decision between the patient and the clinician. These are major factors in considering Mohs surgery as the best treatment for a specifictype of skin cancer.

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Will I Need Reconstruction Of The Resulting Wound

After complete removal of the skin cancer, your surgeon will discuss the best method of managing your wound. The choices include:

  • Letting your wound heal on its own .
  • Closing your wound with stitches .
  • Closing your wound with a skin flap or a graft .
  • A combination of the approaches listed above.
  • Involving another surgical specialist like an oculoplastic or facial plastic surgeon .

Is Mohs Always The Best Skin Cancer Removal Treatment

Cost

There are several reasons that Mohs is a preferred method of skin cancer treatment. However, that does not mean that its the most suitable treatment for every person or every skin cancer tumor. Some of the situations for which Mohs is highly effective include:

  • Skin cancers on the face or other visible areas.
  • Skin cancers in areas where tissue-sparing is imperative, including the hands, feet, eyes, and genitals.
  • Cases in which there is a high risk of recurrence.
  • Cases of recurrent skin cancer.
  • Skin cancers that are very large or fast-growing.
  • Skin cancers with ill-defined borders.

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Why Mohs Surgery Is The Standard Of Care For Skin Cancer Treatment

May 21, 2019 by Stan N. Tolkachjov, MD, FAAD, FACMS

Mohs micrographic surgery is the standard of care for skin cancer removals.

It was first developed to treat non-melanoma skin cancers but is now used to remove many types of skin cancer. Many surgeons are even using Mohs surgery for melanoma. Its highly effective, tissue-sparing, and offers a quick recovery with excellent cosmetic results.

If you is considering Mohs surgery, heres what you need to know about how it works, what it treats, surgery costs, and postoperative recovery.

Are There Risks Associated With Mohs Surgery

The risks associated with the Mohs surgery itself are very low. Please discuss your particular health issues and any concerns about the Mohs procedure with your surgeon. Listed below are the usual risks associated with Mohs surgery:

  • A larger than expected wound.
  • Poor wound healing.
  • Loss of nerve function , which can be temporary or permanent.
  • Regrowth of tumor after removal .

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What Happens Before Mohs Surgery

Before you have a Mohs surgery for skin cancer, youll see your dermatologist for a physical exam of the site and surrounding tissue. Together, you and your dermatologist will review:

  • Your medical history and any medications or supplements you take.
  • The results from your biopsy.
  • Your diagnosis of skin cancer, including your treatment options and the risks and benefits of Mohs surgery.

Depending on your general health and the location of the surgical site, you may need to take preoperative antibiotics.

How Does Mohs Surgery Work

The Difference Between Excision, Staged Excision & Mohs Surgery for removing skin cancer

In Mohs surgery, one doctor serves as the surgeon, pathologist, and reconstructionist. The Mohs surgeon identifies and removes the visible tumor . Then he/she removes a thin layer of tissue around the tumor to spare normal tissue.

The tissue layer is then precisely mapped out, flattened, and evaluated. The doctor examines the margins around the removed tumor peripheral and deep to see if any cancerous tissue remains. By doing this, they see 100% of the margin around the removed tumor. If the tumor is seen under the microscope, additional layers may be needed in only in the precise areas where the tumor remains rather than all the way around the first layer.

Why is that 100% margin so important? It drastically diminishes the chance of the cancer returning as compared to other modes of therapy.

Most skin cancer recurrences come from tumors that were not completely removed because the tumor extended beyond what the clinician could see. Skin cancers may have roots on or under the surface that are invisible to the naked eye. The Mohs technique greatly diminishes this possibility because it shows 100% of the margin microscopically. Since the microscope guidance allows the surgeon to completely see possible tumor extensions and irregularities, all affected areas are removed.

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Why Isn’t Mohs Surgery Used More Often For Melanoma

While standard of care for non-melanoma skin cancers, Mohs surgery is used less frequently for melanoma in situ because melanoma is far more aggressive than other types of skin cancer. When caught early, melanoma is relatively easy to treat and cure. However, once it has spread, melanoma can be deadly. Doctors fear missing microscopic melanoma cells that could end up spreading throughout the body.

In addition, while the edges of non-melanoma skin cancers are easy to see under a microscope, melanoma cells especially atypical melanoma cells are harder to detect. However, in recent years, researchers have refined the Mohs technique with the addition of special stains called immunohistochemistry stains that preferentially stick to the cells that develop melanoma. This helps make melanoma more prominent under a microscope.

After the carpenter was successfully treated, Dr. Wei began to think about Mohs surgery as a potentially viable treatment for more patients, but was shocked at the lack of data comparing the outcomes of patients treated with each approach.

Despite being a small retrospective analysis, the studys results are encouraging. If the findings are verified in a larger, randomized trial, patients who need complex surgery to remove melanoma in situ from sensitive areasthe head, face, hands, and neckcould have more treatment options.

Will Mohs Surgery Leave A Scar

All surgical procedures have the potential for some degree of visible scarring. The appearance of a post-Mohs surgical scar will depend on several factors, including the size and location of the final defect, individual skin characteristics, and the reconstruction options available. You should keep in mind, however, that the tissue-sparing nature of the Mohs technique may result in a smaller, less noticeable scar than other skin cancer removal methods. The Mohs surgeon also may be able to incorporate suture lines into the patients natural skin lines and folds. Most scars improve in appearance naturally over time, and future scar revision techniques may employ if necessary.

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Takeaway For Your Patients

  • Mohs surgery, used for certain BCCs and cSCCs, is done in stages. While the patient waits between each stage, the surgical site remains open and bandaged. The lab work is done on site, and the Mohs surgeon examines 100 percent of the tissue margins from each stage under a microscope. If cancer cells remain, the surgeon removes more tissue for examination from the precise location of the cancer. The doctor repeats this process until no cancer cells remain. The wound is then repaired or, in certain cases, allowed to heal on its own.
  • Mohs has the highest cure rate and lowest recurrence rate of any skin cancer treatment.
  • Mohs is especially valuable for the critical central portions of the face, where preserving normal tissue is essential for function and appearance. It is also valuable for large, problematic, hard-to-diagnose or recurrent BCCs and cSCCs anywhere on the face or body.
  • For small primary tumors on areas of the face or body with no vital, delicate structures, Mohs is often unnecessary. Your doctor can recommend a more cost-effective treatment.

There Is Another Organization Of Mohs Surgeons The American College Of Mohs Surgery What Is The Difference Between The Two Societies

Mohs Micrographic Surgery vs Traditional Surgical Excision: A Cost ...

Both organizations are professional medical societies comprised of practicing Mohs surgeons. Each Society encourages high-quality continuing medical education and quality assurance measures for its members. Both organizations offer membership to Mohs technicians who provide technical support to their member physicians.

The ACMS sponsors its own post-residency fellowship training in Mohs surgery, while the majority of ASMS members received their Mohs training in dermatology residency or post-residency training courses and preceptorships. Some ASMS members also have completed ACMS Mohs fellowships. With our strong organizational emphasis on education, the ASMS encourages physicians to seek all forms of training that will enhance their proficiency in Mohs surgery and other dermatologic procedures. ACMS fellowship training is one option that may or may not be necessary, based on the Mohs surgeons residency training and/or other non-fellowship training experiences.

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What Can I Expect From Mohs Surgery Recovery

Recovery after Mohs surgery depends on the tumor and the patient. Ive had patients from very young to over 100 years old, and most patients get back to normal daily activities quickly especially when tumors on the head and neck are removed. Level of activity, smoking, and other patient factors may affect healing time.

Sutures can be taken out in as little as one week or may dissolve. Patients can resume normal activity within one or two weeks. The scar appearance changes over time, looking significantly better in as little as a month and often fading within a year. The goal is to have a functional and aesthetically pleasing outcome.

When Mohs is done on the torso, legs, or arms, the patients need to limit their activities a little longer than for other areas to prevent sutures from spreading with movement. If non-dissolving sutures are used, I usually ask patients to keep follow-up in two weeks to allow for appropriate recovery in these areas. Its also best to be more cautious with movement in these areas and to have appropriate limits on activity for the best outcome.

Sometimes, the surgeon may recommend small, shallow areas to heal without reconstruction. This leaves a small circular scar that fades over time. These defects require no downtime beyond the day of surgery, but they do take longer to fully heal as little as three weeks for patients who recover quickly and as long as three months for patients with poor circulation.

Who Is The Ideal Candidate For A Mohs Surgery

The ideal candidate for a Mohs surgery has a basal cell carcinoma , squamous cell carcinoma , or, in some cases, a melanoma in any area of the body. Mohs Surgery is not recommended for those with superficial, small, or low risk BCCs or SCCs in non sensitive areas that can be treated via other treatments like surgical excision or cryosurgery.

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What Happens If I Do Not Have My Skin Cancer Treated With Mohs

Mohs may be considered the gold standard in skin cancer removal procedures but there are other options you might consider. Your dermatologist can discuss the best options for you based on your situation. These may include freezing the skin cancer , excising it using standard excisional techniques, or using medication to destroy the cancer cells. Keep in mind that standard excision removes all of the visible growth as well as some of the surrounding tissue. This can result in significant scarring and may not completely eradicate the cancerous cells.

Whether You Also Need Reconstructive Surgery

What Is Mohs Surgery?

The incisions created by Mohs surgery often heal in a more desirable way than other skin cancer treatment options, but your surgeon may opt to work in tandem with a reconstructive or plastic surgeon, to ensure you get the best cosmetic results possible. This is especially likely if you’re being treated in a very visible area, like your face.

Adding another physician will add a second surgeon’s fee to your total bill.

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Is The Mohs Surgery Worth The Money

Mohs surgery has earned a 98%Worth It Rating from the RealSelf community, so most people who reviewed their procedure think the results were worth the expense.

Mohs micrographic surgery is a highly specialized type of surgical excision that effectively removes common types of skin cancer, including basal cell carcinoma and squamous cell carcinoma .

Mohs surgery offers the highest cure rate of BCC and SCC of any skin cancer removal technique, with minimal recurrence rates.

It also offers some of the best cosmetic results of any skin cancer treatment option. Its precise nature means that it spares more healthy tissue than most surgical excision methods, minimizing scarring and the need for reconstructive surgery.

It can be more expensive than other forms of skin cancer removal, but Mohs usually ends up being a more cost-effective option due to its low recurrence rates.

Does Mohs Leave A Scar

If you choose to undergo Mohs surgery for skin cancer, you can expect a scar. Scarring is an inevitable part of broken skin, which is why you can develop scars from tiny scrapes or cuts. The severity of scarring after Mohs micrographic surgery usually correlates to the characteristics of your tumor. Scarring after Mohs may look more significant than expected. This can happen because the visible growth looked small on the surface but spread wider through deeper layers of the skin. One of the advantages of the Mohs procedure is that it incurs smaller scars than standard skin cancer excision. According to studies, most Mohs scars fade a great deal in the year following surgery. In some cases, though, a plastic surgeon or dermatologic surgeon may perform a minor scar revision procedure. There are several ways to minimize scarring after having Mohs. Your treating dermatologist can discuss the options that may be best for you.

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What Are The Advantages Of Having Mohs Surgery

The most important advantages of Mohs surgery are the complete microscopic examination, which allows for complete removal of the cancer and high cure rates, and the ability to spare as much normal skin as possible.

Additional advantages of Mohs surgery for skin cancer include:

  • Its done in a single outpatient visit.
  • Youll receive local anesthesia to numb the area, so youll recover faster compared to general anesthesia or sedation.

How Does It Work

Mohs Micrographic Surgery vs Traditional Surgical Excision: A Cost ...

In Mohs surgery, once you are given a local anesthetic , the surgeon removes all visible areas of skin cancer. Then the surgeon removes a layer of surrounding skin.

You are bandaged, and the surgeon looks at the layers of skin removed to check for cancer cells. If any are found, the surgeon will unbandage you and remove another layer of skin. That layer is then checked for cancer cells, as well. This is repeated until cancer cells are not seen anymore.

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Where Your Surgical Procedure Is Performed

If you live in a major city, you know firsthand that prices for everything, including dermatologic procedures, are higher, simply because of the higher cost of living. The upside: you’ll likely have a bigger selection of Mohs surgeons. You may also find that qualified surgeons in different areas of the city provide very different price quotes.

The type of surgical facility also matters. In-office procedures are the most affordable, while you’ll pay more if your provider performs this procedure in a surgery center.

A hospital operating room will come with the most hefty facility fee, so if you’re paying out of pocket, try to avoid this option.

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