What is Mohs Micrographic Surgery?
According to the Centers of Medicare & Medicare Services (CMS), "Mohs Micrographic Surgery (MMS) is a technique for the removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. It is a combination of surgical excision and surgical pathology that requires a single physician to act in 2 integrated but separate and distinct capacities: surgeon and pathologist."
MMS is a highly effective and extremely advanced technique used in the treatment of several types of dangerous skin cancers (listed below). The process involves removing skin cancers in a systematic and gradual manner, where skin is removed layer-by-layer, and the complete depth and circumference is examined one cell at a time under a microscope until only cancer-free tissue remains. This ensures maximum effectiveness at cancer eradication with minimal damage to the healthy surrounding tissue. Fellowship trained Mohs surgeons, such as Dr. Hazany, have spent an additional 1-2 years perfecting their craft under the supervision of a world renowned Mohs surgeon, where they learn the most current and specialized techniques. The advanced techniques Dr. Hazany learned in his fellowship are particularly effective for areas that require precise reconstruction such as the face and those that require delicate precision such as the hands.
Why is it important that my surgeon be fellowship trained?
In addition to their three year dermatology residency, fellowship trained Mohs surgeons undergo rigorous training and specialization to sharpen their surgical skills and perfect cutting-edge techniques under the supervision of an accredited group of physicians. During his fellowship, Dr. Hazany completed over 3000 supervised and solo complex reconstructions of the nose, eyelids, ears, lips, face. fingers, hands, feet, extremities and genitals. Dr. Hazany is a member of the America College of Mohs Surgeons (ACMS), a prestigious organization for the top fellowship trained surgeons that requires continued education and community involvement. Many dermatologists perform Mohs Surgery without completing a fellowship or do so with inadequate training and minimal experience. Many of these surgeons are members of the American Society of Mohs Surgery (ASMS), an organization which has comparatively minimal criteria for membership. The differences in the surgeon's training, technique, and experience are very apparent in the final product in side-by-side comparisons.
The Three Steps to Mohs Surgery:
Mohs surgery involves three steps 1) surgical cancer removal, 2) pathological review of the complete skin margins and depth using a microscope, and 3) reconstruction of the post surgical wound. All three steps should ideally be performed by the same highly skilled surgeon that is familiar with the case from the start to the end of the reconstruction. In the first step, the part of the tumor that is visible to the naked eye is marked and removed. At this point the surgeon removed a thin layer of the remaining skin and prepares a sample for the microscope. The sample is then examined to search for any indication of remaining cancer cells. In the case that signs of high risk cells exist in the sample, the surgeon proceeds to remove another layer of remaining skin for examination until the sample is devoid signs of potential danger. When the circumference and depth of the final layer reveal completely healthy skin cells, cancer free margins have been achieved and reconstructive planning begins. It is important to note that all three steps of Mohs surgery are performed while the patient is comfortable and awake and completely anesthesized using local numbing medicines. If mild oral sedation is necessary, that can also easily be made available to the patient to help take the edge off during surgery.
When is Mohs appropriate?
The following pathologic tumor subtypes can be treated with Mohs surgery (patient health status, size and location also play a role in appropriate treatment planning.
Basal Cell Carcinoma
Squamous Cell Carcinoma, Keratoacanthoma
Lentigo Maligna and melanoma in situ
Primary lentigo maligna
Extramammary Paget Disease
Malignant fibrous histiocytoma
Merkel Cell Carcinoma
Microcystic Adnexal Carcinoma
Rare Biopsy proven malignancies not otherwise specified