Advanced Dermatology, Mohs & Laser Surgery Center, P.A.
240 East Grove St.
Westfield, NJ 07090
P: 908-232-6446/F: 908.232.6447

MOHS SURGERY
Microscopically Controlled Surgery
 

SABATINO CIATTI, M.D.

240 East Grove St.
Westfield, NJ  07090 
908.232.6446
908-232.6447
and
20 Community Pl. Suite 104
Morristown, NJ  07960
973.538.1560
973.538.1544

ABOUT THE DOCTOR

Sabatino Ciatti, M.D. is a summa cum laude graduate and Phi Beta Kappa Honor Society recipient of Lehigh University.  He received his medical degree from the University of Medicine and Dentistry of New Jersey, where he graduated with highest honors and was a recipient of the Alpha Omega Alpha Honor Society.  He trained in dermatology at Jefferson Medical College in Philadelphia, Pennsylvania, where he was chief resident.  He then went on to fellowship training in Mohs micrographic surgery, dermatologic surgery, and laser surgery, also at Jefferson Medical College.  He limits his practice to dermatologic/cosmetic surgery, laser surgery and Mohs micrographic surgery.

Dr. Ciatti is board-certified in dermatology and dermatologic surgery.  He is a fellow of the American Academy of Dermatology, American Society for Dermatologic Surgery and the American College of Mohs Surgery (membership restricted to fellowship-trained Mohs Surgeons).  Dr. Ciatti has published a number of articles in the dermatologic literature.  He is on staff at Overlook Hospital.  He is a member of the Union County and New Jersey State Medical Societies as well as the Dermatological Society of New Jersey.

WHAT IS SKIN CANCER?

Skin cancer is the most commonly diagnosed cancer in the United States.  There are an estimated 3,500,000 new cases per year.

The skin is a collection of cells organized as a unit.  Normally, skin cells divide to replace ones that have died from either old age or injury.  These new skin cells arise from the deepest level of the skin and push their way toward the surface as they mature.

The main types of cells found within the skin are basal cells, which form the bottom layer, squamous cells, which form the upper layers that we see, and melanocytes, which produce melanin, the pigment that colors the skin.  The abnormal and uncontrolled growth of any one of these cell types can give rise to a skin cancer.  The three most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma and malignant melanoma, named after the respective cell types from which they originate.  There are some other types of skin cancer, which are much rarer.

Basal Call Carcinoma

Basal cell carcinoma is the most common skin cancer found in Caucasians.  An estimated 2.8 million are diagnosed annually in the US.  Itseldom occurs in dark-skinned individuals.  Basal cell carcinoma usually appears as a small pearly nodule (‘a bump’) primarily on the head and neck; on the trunk they appear to have a flatter appearance.  Often patients describe them as a “pimple that bleeds and won’t go away.”  Basal cell carcinomas typically grow at a slow pace and usually do not spread (metastasize) to other parts of the body.  Left untreated, however, these cancers have a greater potential for local destruction and about a 1 in 10,000 chance of metastasizing.

Squamous Cell Carcinoma

Squamous cell carcinoma is the second most common skin cancer found in Caucasians.  It develops in approximately 80,000 to 100,000 persons per year.  It is rarely found in dark skinned individuals.  Squamous cell carcinomas may appear as a nodule or a red, scaly patch.  They occur most commonly on the rim of the ear, the face, the lips and mouth. Left untreated, squamous cell carcinomas have a higher potential to spread to other parts of the body in comparison to basal cell carcinomas, particularly if they are on the lip or in the mouth.

Malignant Melanoma

Malignant melanoma is a skin cancer which can be life threatening if it is not diagnosed and treated early.  Fortunately, it is far less common than basal cell and squamous cell carcinomas, with an estimated 30,000 – 45,000 persons affected per year.  Melanoma usually occurs in adults, but it may be found in children and adolescents.  Melanoma appears as a small brownish-black or larger multicolored patch, plaque, or nodule with an irregular outline.  Sometimes there may be crusting, bleeding and even itching.  Although most melanomas develop as a new lesion, some develop from moles, which have been present for years.  Any mole, birthmark or beauty mark that changes in color, increases in size or thickness, changes in texture, or develops an irregular border should be evaluated since these changes could be the sign of a mole changing into skin cancer.  When melanomas are discovered and treated early, they are nearly 100% curable; deep, large, neglected melanomas often result in death from metastases.

WHAT CAUSES SKIN CANCER?

Sunburn and Sunlight

The single most significant predisposing factor for the development of skin cancer is chronic ultraviolet light (sunlight) exposure.  This explains why the majority of skin cancers appear on the face and other sun-exposed sites.  Ultraviolet (UV) rays are divided into UVA, UVB, and UVC.  UVB rays are primarily responsible for skin cancer; however, UVA rays also contribute to skin cancer as well as aging and wrinkling.  Tanning parlors typically use UVA rays. Up to 80 percent of a person’s lifetime exposure to the sun may occur by 18 years of age. Because skin cancers are slow growing, it may take 20 or more years to develop a skin cancer from a sun burn occurring earlier in life.  Even though most sun damage probably occurs early in life, it is important to protect the skin from further damage as one is aging.

Heredity

Ongoing research suggests that there may be a genetic or hereditary factor contributing to skin cancer.  There is often a family history of skin cancer.  Northern Europeans(northern Italian, Irish), who tend to have fair skin, develop more skin cancers than dark-skinned people.

Environment

Due to a reduction of ozone in the earth’s atmosphere, a higher level of ultraviolet light reaches the earth’s surface.  People who live at higher altitudes or near the equator, are exposed to higher levels of ultraviolet light and thus develop more skin cancers.

Other Causes

Superficial X-rays (Grenz rays) which were used many years ago for the treatment of certain skin disorders, including acne, can sometimes cause kin cancer many years later.  Chest X-rays and dental X-rays do not cause skin cancer.  Trauma (burns and scars), several chemicals, and certain rare inherited diseases can also contribute to the development of skin cancer.

WHAT SHOULD I DO IF I SUSPECT THAT I HAVE SKIN CANCER?

Need for Biopsy

If you develop any of the signs or symptoms of a skin cancer as discussed above (i.e. a non-healing growth, or a changing mole), you should have the growth evaluated.  Often you will need a skin biopsy to verify that it is a skin cancer; this will also determine the type of skin cancer.  The biopsy is performed with local anesthesia (an injection).  The biopsy only removes the superficial portion of the skin cancer.  If the biopsy confirms that there is skin cancer, it will need to be completely removed, usually by surgery.  Sometimes the biopsy site will heal over and appear as though the skin cancer is gone; however, the “roots” of the skin cancer are still there and if it is not totally removed, it will grow again, often larger than the initial growth.

HOW IS SKIN CANCER TREATED?

There are several kinds of treatment for skin cancer, which are all highly successful in the majority of patients.  The majority of treatments are surgical.  These include simple excision (cutting and suturing), curettage and electrodessication (scraping and burning with an electric needle), and Mohs surgery (microscopically controlled excision).  Sometimes, radiotherapy (x-ray) is used.  The method chosen depends on the size and location of the cancer, the type of cancer, and previous therapies.

WHAT IS MOHS SURGERY?

In 1941, Dr. Frederic Mohs described a form of treatment for skin cancer, which he called chemosurgery.  This technique involved applying a zinc chloride paste to the tumor to “fix the tissue.  The tissue was then subsequently excised (cut) and then sectioned into thin slices to be looked at under the microscope.  This technique has since come to be known as ‘Mohs surgery’ in honor of Dr. Mohs.  The procedure has been refined and improved upon since Dr. Mohs first described it.  It is no longer necessary to use a zinc paste; all cases are now done using the “fresh tissue” technique.

Mohs surgery is a highly specialized treatment used primarily in the removal of basal cell and squamous cell carcinomas.  The microscope is used to assess the extent of the tumor and its location.  The idea is to be certain that the tumor is completely removed while conserving the normal tissue surrounding the tumor.  This becomes especially important in areas where there is little excess tissue, i.e. the face.  Sometimes the tumor may appear to be quite small on the surface, but may be more extensive when viewed microscopically.  If it were to be treated by simple excision, the tumor might not be completely removed and a second procedure would be necessary upon evaluation by an outside laboratory.

Surgical Procedure

The apparent skin cancer is outlined with a marker.  A pre-operative photograph is taken to document the location and size of the tumor.  A local anesthetic is then injected into the area so that there is no feeling of pain.  The anesthetic feels like a ‘small pinch and a burn’.  Once the area is numb, the cancer is scraped with a sharp instrument known as a curette to better define the margin.  A thin slice of tissue is then surgically removed around the scraped skin and placed on a ‘map’ of the surgical site to maintain the correct orientation of the tissue.

Examination of Tissue

Depending on the dimensions of the tissue removed, it is divided into either halves or quarters.   The edges of the cut tissue are then marked with special colored dyes so that the orientation and relation to the area from which it came can be determined.  This is all carefully diagrammed on the ‘map’.  The tissue is then frozen by the technician.  The tissue is then cut into thin slices, placed on glass slides and then stained by a series of special tissue stains. The slides are then examined by the doctor under the microscope to determine if the skin cancer is present at any of the tissue margins.

Duration of Surgery

The removal of each layer of the tissue requires approximately 15-20 minutes.  Once the layer is removed, any bleeding (which is usually small) is controlled using a combination of pressure and electrocautery.  Sometimes a suture may be required to tie off a small blood vessel.  Once bleeding is controlled, a pressure dressing is applied and the patient is asked to wait in the waiting room where you may read a book, watch TV, etc.  Although the surgery requires only 15 – 20 minutes per layer, the processing of the tissue and interpretation may require 1-2 hours.  The interpretation involves looking at each of the slides, determining if there are any areas, which have tumor at the margin, and marking these areas on the ‘map’.  If there are any areas of residual tumor, then the removal of a second layer is required.  The procedure for the removal of each layer is the same as the first layer. Typically, it takes one or two layers (also called ‘stages’) of tissue to completely remove a tumor.

WHAT HAPPENS AFTER THE TUMOR HAS BEEN REMOVED?

Once the edges and periphery of the tumor site are determined to be free of tumor by the Mohs surgeon, the Mohs procedure portion of your surgery is complete.  At this time a photograph is taken to document the size and nature of the wound resulting from the Mohs surgery.

Once the Mohs procedure is completed, you will be left with a surgical wound.  This wound will be dealt with in one of several ways.  The options will be discussed with you;  the goal is to provide the best feasible cosmetic result.  The possibilities include: (1) healing by spontaneous granulation; (2) closing the wound or part of the wound with sutures (stitches) using either simple closure or plastic surgery techniques such as flaps and grafts; or (3) rarely, arranging a consultation with one of several physicians who are skilled in performing various reconstructive procedures.  Upon completion of the Mohs surgery, the optimal choice for your individual case will be recommended to you.  In most cases, this will be choice (2).

Spontaneous granulation

Healing by spontaneous granulation involves letting the wound heal by itself.  This allows for observation of the wound as it heals after the removal of a tumor.  Experience has shown us that there are certain areas of the body where nature will heal a wound as nicely as any further surgical procedure.  If the wound does not heal with an acceptable scar, cosmetic surgery to improve the scar can be performed at a later date.  Healing by spontaneous granulation can take as long as four to eight weeks to heal completely depending on the size of the wound and on how quickly the individual tends to heal.

Closure with Sutures (stitches)

For small lesions, the wound is often closed with sutures.  This involves some adjustment of the wound (such as loosening of the wound edges) and sewing the edges together.  With larger wounds, a flap or graft may be required to close the wound.  A flap involves ‘borrowing’ tissue from a site adjacent to the wound by cutting and undermining (loosening the attachment of the tissue) and then bringing that tissue into the wound and securing it with sutures.  Both simple side to side closures and flaps are done in a way to hide the scar within natural facial or wrinkle lines (i.e. plastic surgery).  If the wound is large and there is not enough adjacent tissue to ‘borrow’ from, then a graft may be used.  This involves taking tissue from a donor site such as the back of the ear and suturing that donor skin onto the wound.  The donor site is then either sutured or left to heal by spontaneous granulation.

WHY MOHS SURGERY?

Mohs micrographic surgery is the state-or-the-art treatment for skin cancer in which the physician serves as surgeon, pathologist and reconstructive surgeon.  It relies on the precision and accuracy of the microscope to trace the skin cancer down to its ‘roots’ and ensure its removal.  It offers the highest cure rate (97-99%) of any method, even if other methods have failed.  Because normal tissue is preserved to the greatest extent possible, Mohs surgery offers the possibility of a good cosmetic result while minimizing the potential for scarring and disfigurement.

Mohs surgery should be the treatment of choice when: (1) the cancer is large; (2) the edges of the cancer cannot be clearly defined; (3) the cancer is on an area of the body where it is important to preserve healthy tissue for the maximum functional and cosmetic result, or is likely to recur if treated by common methods (eyelids, nose, ears, lips); or (4) prior treatment has failed.

WHAT HAPPENS AT THE PRE-OPERATIVE VISIT?

At the pre-operative visit (consultation) the physician will have an opportunity to examine your skin cancer, take a pertinent history and determine whether the Mohs technique is the most suitable way to treat your skin cancer.  The pre-operative visit also gives the patient an opportunity to meet the surgeon and to learn about the surgical procedure.  (In some cases, a pre-operative visit may be unnecessary if your referring physician has determined that the Mohs technique is suitable.)

If you have been referred to us, usually a biopsy of the skin cancer has been performed, and we have a pathology report stating the type of skin cancer present.  If a biopsy has not been obtained, then we will perform the biopsy at the initial visit.

If it is determined that the Mohs procedure is suitable for your skin cancer, a mutually acceptable date for your surgery will be arranged.  You will also be given a “consent to surgery” form to read and sign.

HOW DO I PREPARE FOR THE DAY OF SURGERY?

Please pay particular attention to the following information regarding medications.

You should take all of your medications as prescribed.  Regarding anticoagulants (blood thinners), policies for discontinuation of such agents has changed.  You should discontinue agents such as fish oil, vitamin E, Ginko, Ginseng, NSAIDs (e.g. ibuprophen, Aleve) for 7 – 10 days prior to surgery.

You should continue to take prescribed anticoagulants such as Coumadin (warfarin), Plavix, Pradaxa, Xarelto, and aspirin as prescribed by your internist or cardiologist. 

If you are on Coumadin (warfarin) we ask that your INR be 2.5 or less… please check with your internist/cardiologist.

If you are on multiple anticoagulants, we ask that you check with your internist/cardiologist about staying on one agent and discontinuing the others temporarily.

For example, if you are on Coumadin, Plavix, and aspirin, you would continue with your Coumadin, but discontinue Plavix and aspirin for 5 – 7 daysIf you have any questions regarding discontinuation of any agents, please call our office.

If you have any prostheses (e.g. artificial knee, heart valve, etc.) and/or have a history of mitral valve prolapse/heart murmur, you may require pre-operative and post-operative antibiotics.  Often, patients have already been told by their primary physician that any surgical procedure requires these antibiotics.  Please be sure to make us aware of the need for these antibiotics.

Wounds are best kept dry, particularly for the first few days following surgery.  For this reason, we recommend that you take a thorough bath or shower (including washing your hair) on the eve or morning of the surgery.

A light meal prior to the surgery is fine.  Remember to bring a book or magazine to read as there will be a fair amount of waiting in between the tissue stages.  It is advisable to bring someone with you.  Although in most cases you will probably be able to leave on your own, it may be better to have someone drive you home.

WHAT HAPPENS ON THE DAY OF SURGERY?

You will be placed on the surgical table, and the area around your skin cancer will be anesthetized (numbed) with a local anesthetic.  This may be somewhat uncomfortable for a few seconds, but typically this is the only discomfort that you will experience during the procedure.  Once the area is numbed, a layer of tissue will be removed and any bleeding will be controlled.  The removed tissue will be processed as has been discussed previously.  Once a pressure dressing is applied over the surgical wound, you will be free to leave the surgical suite.  You will have the opportunity to read a book, etc. in the waiting room while the tissue is processed and interpreted.  Typically this takes about one hour.

Most Mohs surgery cases are completed in one or two stages.  The majority of cases are completed within 3-4 hours.  Once the skin cancer is removed, we will discuss with you our recommendation for repairing the surgical wound. The reconstructive surgery typically takes about 45-60 minutes to complete.

WHAT CAN I EXPECT AFTER THE SURGERY?

Pain

Following surgery, you should have little or no discomfort.  If you do have some discomfort, we ask that you take Tylenol (acetaminophen), unless otherwise indicated (e.g. liver disease).  You should avoid aspirin and aspirin-like medications because these may promote bleeding.  Rarely, it may be necessary for the physician to prescribe a stronger pain medication.

Bleeding

Rarely does bleeding occur following surgery.  If this does occur, it can usually be controlled with pressure.  Simply apply a gauze pad over the wound, lie down, and apply constant pressure over the bleeding point for 15-20 minutes.  Do not relieve the pressure at all during that period of time. If bleeding persists, repeat the pressure for another 20 minutes.  You may also apply an ice pack over the bandage as you are holding pressure.  If this fails, then call the office or service and proceed to the nearest hospital emergency room.

Complications

Minor complications can sometimes occur after Mohs surgery.  Often a small area of redness may develop around your wound.  This does not necessarily imply infection.  If the redness persists for more than two days or if the wound is tender and drains pus, notify our office immediately.  Itching and redness around the wound, in areas where adhesive tape has been applied, are not uncommon.  You should try to use a non-allergenic tape such as paper tape.

Swelling and bruising are fairly common following Mohs surgery, especially if the surgery is performed around the eyes.  These conditions usually subside within four to five days and may be decreased by sleeping with the head slightly elevated and by using an ice pack for short periods of time during the first 24 hours.

Sometimes, the area surrounding the surgical site will be numb to the touch.  This numbness may persist for several months or longer.  In some cases, the numbness may be permanent.  If this occurs, you should discuss it with your physician at your follow-up visit.

Often as wounds heal in, they can be itchy.  If the wound is healing in by spontaneous granulation, there can be a sensation of tightness from contraction of the tissue.  This sensation subsides with time.

Restrictions

Often we will recommend that you restrict excessive physical activity (e.g. exercise, lifting, etc.) for several days to a week.  Details will be discussed with you after surgery.

Wound Care

Detailed instructions for wound care will be provided following the surgery.  Usually this involves cleaning the wound with 3% hydrogen peroxide,   applying an antibiotic ointment such as Bacitracin, Polysporin, or double antibiotic ointment (we don’t recommend Neosporin or triple antibiotic because there is a higher incidence of allergic reaction to Neomycin in these products), followed by a non-stick bandage such as Telfa.  This is usually done twice a day.  If a graft is used to repair the surgical wound, a ‘permanent’ bandage will be placed by us; this will not be removed until we see you for follow-up in 1 week.  In all cases, the wound should be kept as dry except for the use of hydrogen peroxide.

Follow-up

Typically, the majority of patients are seen one week following the Mohs surgery for suture removal.  If sutures were not used in the repair, then the patient may be seen two or three weeks following surgery.  Sometimes the surgical scar will require modification or further treatment (with laser, cortisone injection, etc. ) to obtain the best cosmetic result.  Periodic follow-up to assure that the surgical wound is well healed and that there is no evidence of recurrence will be necessary.

A follow-up period of observation for at least five years is indicated.  Once the wound has completely healed to satisfaction, you should follow-up at least twice a year with your referring physician.  If there is a recurrence, it usually occurs within the first year following surgery.  If you notice any irregularity of the scar or any new lesion, you should consult your referring physician and/or dermatologist as early as possible to see if a biopsy is indicated.

WILL I DEVELOP MORE SKIN CANCERS?

Studies have shown that those who develop one skin cancer are susceptible to developing others in the years ahead.  Although most of the sun damage occurs before the age of twenty and cannot be reversed, you can protect yourself from further sun damage by taking some precautions.

1.     Minimize your sun exposure during the hours of 10AM and 2PM (11AM to 3PM daylight saving time) when the sun is strongest.

2.     Wear a hat, long-sleeved shirts and long pants when out in the sun.  Chose tightly-woven materials for greater sun protection.

3.     Apply a sunscreen with an SPF of 30 or higher to all exposed skin.  You should reapply it frequently and liberally, at least every two hours.  It should always be reapplied following swimming.

4.     Use sunscreen on overcast days also.  The suns rays are as damaging on cloudy, hazy days as they are on sunny days.

5.     Sitting in the shade does not always protect you.  Sand, snow, concrete and water can reflect the sun onto your skin, so wear sunscreen even in the shade.

6.     Activities at high altitudes and near the equator expose you to stronger sun rays.  Sunscreen should definitely be applied in these situations.

7.     Avoid tanning parlors.  Although most skin cancers are caused by UVB, UVA (used in tanning parlors) does increase your risk of skin cancer and certainly causes premature aging

 

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