Mohs Surgery

Not every skin cancer requires Mohs surgery for the best outcome.

This highly technical surgery is usually reserved for certain circumstances, specifically:

• To treat skin cancers located in cosmetically sensitive or functionally critical areas such as the face, scalp, ears, hands and feet where tissue conservation and optimal cosmetic outcomes are paramount.
• When the tumor is large and has indistinct, poorly-defined margins.
• When there is a high risk of future cancer recurrence.
• To remove a recurrent skin cancer that has come back after previous treatments.
• When the tumor is located in or near scar tissue.
• When the tumor is aggressive and fast growing.
• When the patient is immunosuppressed.

Mohs surgery is a highly specialized and precise procedure performed by fellowship-trained surgeons with advanced training who act as both surgeon and pathologist. At Apex Skin Center, your procedure will be performed by a board-certified dermatologist with fellowship training in Mohs surgery and extensive reconstructive training.  The Mohs technique is labor-intensive and a multidisciplinary team with an experienced histotechnician with specific training in Mohs frozen tissue processing, a fully certified Mohs laboratory, and well-trained clinical staff.

The Mohs surgery visit starts with a consultation with Dr. Thomas Knackstedt. As an experienced Mohs surgeon having performed over 10,000 cancer surgeries, Dr. Knackstedt will review the nature of your cancer, the procedure, and the expected recovery with you in detail.

The procedure begins with the administration of local anesthesia to numb the area surrounding the tumor, ensuring your comfort throughout the procedure. The surgeon then carefully removes the visible portion of the tumor along with a thin layer of surrounding tissue. This tissue is precisely mapped and labeled with colored dyes before being processed. In our state-of-the-art laboratory, the specimen is frozen, cut, placed on a glass microscope slide and stained to provide information about the pattern, shape, and structure of the cells.

Using a microscope, the surgeon meticulously examines the tissue to identify any remaining cancer cells at the margins. If cancer cells are detected, the surgeon precisely marks their location on the corresponding map, allowing for targeted removal in subsequent stages.

The patient remains in the procedure room while the tissue is being examined, enabling real-time assessment and immediate additional tissue removal if necessary. This process of removal, mapping, and microscopic examination is repeated until the entire tumor is completely removed with clear margins, minimizing the chances of cancer recurrence.

Mohs surgery takes several hours, however, most of the time is spent creating and reviewing the microscope slides to determine if your cancer has been completely removed. This process eliminates the need to overestimate the size of the tumor and take an unnecessarily large margin of safety. Mohs surgery allows for preservation of the greatest amount of noncancerous tissues. The outcome is a significantly better cosmetic result with a lower chance of cancer recurrence.

The majority of wounds after Mohs surgery can be closed in a linear (straight line) fashion or allowed to heal on their own. Larger or more complex wounds in cosmetically sensitive and functionally important areas may be repaired with a skin flap or skin graft. Depending on a number of variables, a wound may be stitched with dissolvable sutures or permanent sutures that need to be removed at a follow-up visit. Dr. Knackstedt will involve you throughout the reconstruction process, review of potential options, and any important decision making. The degree and frequency of follow-up visits after your Mohs surgery is determined by your preferences, the characteristics of your cancer, and the nature of your wound repair.

Whenever the skin is broken or incised into, there will always be a scar. Careful surgical technique minimizes scarring. Your surgery will always be performed by a board-certified who is experienced in minimizing scar appearance.

Your wound may be tender 1-2 hours after the excision when the local anesthetic wears off. Most often, only over-the-counter acetaminophen (Tylenol) and/or ibuprofen (Motrin/Advil) is all that is needed. Icepacks also help with pain reduction and decrease swelling or bruising.