Mohs Information Packet

​Mohs Information Packet​ ​www.swanndermatology.com​

​Michael Swann MD, MS FAAD​ ​Dr. Michael Swann specializes in all aspects of dermatologic surgery with special emphasis on Mohs​ ​micrographic surgery (a precise technique to remove skin cancers), reconstructive surgery, laser and cosmetic​ ​dermatology. Dr. Swann is a board-certified dermatologist and fellowship trained Mohs surgeon whose primary​ ​focus is to surgically remove skin cancers using the Mohs micrographic surgical technique. Dr. Swann also has​ ​extensive experience in reconstructive surgical repair of Mohs surgery defects. He did an advanced fellowship​ ​in Procedural Dermatology, combining skin cancer & Mohs surgical training with advanced laser & cosmetic​ ​procedures.​

​Dr. Swann grew up in Springfield and graduated from Kickapoo High School. He​ ​received his M.D. degree from the University of Oklahoma and was appointed to​ ​Alpha Omega Alpha, the medical school’s highest honor. Dr. Swann completed an​ ​internship in Internal Medicine and Residency in Dermatology at the University​ ​of Missouri-Columbia. He then completed a fellowship in Procedural​ ​Dermatology (Mohs Surgery, Laser & Cosmetic Dermatology) at prestigious​ ​Scripps Clinic in La Jolla, California under the directorship of Dr. Hubert T.​ ​Greenway who is one of the few physicians trained directly by Dr. Mohs in​ ​Madison, Wisconsin. Dr. Swann completed a fellowship in laser & cosmetic​ ​dermatology at one of the leading laser & cosmetic procedure clinics on the west​ ​coast under the direction of Victor Ross, MD. Additionally, Dr. Swann holds a​ ​master’s degree in electrophysiology and trained in advanced vascular treatments​ ​including foam sclerotherapy, ambulatory phlebectomy and endovenous ablation​ ​with renowned cardiothoracic surgeon Dr. Leeland Housman. Dr. Swann is​ ​board-certified in dermatology by the American Academy of Dermatology and​ ​entered private practice in 2008, bringing southwest Missouri a wide range of​ ​expertise in surgical dermatology.​

​Dr. Swann is devoted to dermatology surgery and is a speaker at national dermatology meetings on the topic of​ ​Mohs micrographic surgery and skin cancer. He is active in the following organizations: American College of​ ​Mohs Surgery, American Board of Dermatology, American Academy of Dermatology, American Society of​ ​Dermatologic Surgery, American College of Phlebology, American Society for Lasers in Medicine and Surgery.​

​CLICK HERE FOR DR. SWANN INTRODUCTION VIDEO!​

​Skin Cancer​ ​Skin cancer is the most common type of cancer​ ​. More than 3.5 million​​skin cancers are diagnosed annually​ ​in more than 2 million people. Current estimates are that one in five Americans will develop skin cancer in​ ​their lifetime.​ ​Basal cell carcinoma​ ​(BCC) and​ ​squamous cell carcinomas​ ​(SCC) are the two most common​ ​forms of skin cancer, but both are easily treated if detected early. These tumors most commonly arise from​ ​genetic mutations in the skin caused by sun damage. Fair complexion, light eyes (blue, green, hazel) and family​ ​history of skin cancer all increase a person’s risk for developing skin cancer. Patients who take​ ​immune-suppressing medicines, those with a history of bad sunburns or certain medical conditions (leukemia)​ ​are also at increased risk for developing skin cancers.​ ​If not completely removed, skin cancers invade and destroy important structures. Although basal cell​ ​carcinomas rarely metastasize (spread to other parts of the body), squamous cell carcinomas can develop and​ ​spread more quickly.​ ​Melanoma​ ​, the third most common​​type of​ ​skin cancer is the most likely to spread and can be very dangerous. Melanoma is most commonly treated by​ ​excision with a margin, but is treated by Mohs surgery in some instances.​ ​Mohs Surgery​ ​Mohs micrographic surgery is a specialized surgical procedure used to treat skin cancers, typically of the head​ ​and neck. Certain tumors of the rest of the body are sometimes treated with Mohs surgery as well. The​ ​technique offers two main advantages over traditional skin cancer removal treatments:​ ​•​ ​The highest cure rate​ ​. Mohs surgery for primary​​basal cell carcinoma, for example, has a 98- 99% cure rate.​ ​•​ ​Tissue sparing​ ​. Because Mohs surgery is a tissue​​sparing surgery, where only the skin with tumor in it is​ ​removed, the patient is left with the smallest defect possible. Smaller defects mean smaller scars in the end,​ ​after the defect is closed. In traditional excisions, the edges are not checked in "real-time" so safety margins are​ ​necessary. This often leads to larger defects and eventually larger scars. On the face, even a couple of​ ​millimeters difference in a scar length can make a big cosmetic difference. (See below for more about scars.)​ ​Not all tumors require Mohs surgery and other good treatments are available for skin cancer. The most common​ ​treatment for skin cancer is physical destruction by either cryotherapy (freeze-treating) or curettage with​ ​electrodessication (scrape & burn). Topical chemotherapy (prescription cream) is sometimes used for pre-cancer​ ​or very early skin cancers. A newer technique for treating early tumors include photodynamic therapy (PDT),​ ​whereby a medicine is applied to the treatment site and later activated by narrow-band light therapy. Tumors​ ​without aggressive features in areas that do not require tissue sparing may also be treated by standard excision​ ​(cutting the tumor out and immediately sewing it up, without checking to see if it is clear first).​ ​Mohs surgery involves a​ ​same-day procedure​ ​where an initial "layer" is taken (the clinical tumor) and​ ​examined under the microscope for any involvement of the edges while the patient waits. The tissue is mapped​ ​in such a way so that if there is tumor at any one edge, the surgeon knows exactly which edge this is and can go​ ​back to take another small piece of skin from this edge only (instead of another whole circle around the defect,​ ​leaving a larger defect than necessary).​ ​Repair/Reconstruction​ ​Once the Mohs surgery is complete, you will have a wound or defect where the cancer was located. This wound​ ​can vary in size but will always be larger than what was seen initially with the naked eye. The second part of the​ ​procedure is repairing this wound. Although Mohs surgery allows for maximal tissue preservation, all surgery​ ​results in a scar. Your provider is an experienced reconstructive surgeon and will review the options and​ ​recommend the repair that would likely result in the best cosmetic and functional outcome.​ ​Common Types of Repairs:​

​• Primary Closure: The skin around the wound is loosened then closed in a straight line using layers of deep and​ ​superficial sutures. The incision line will be longer than you may expect as the final length is usually three to​ ​four times as long as the diameter of the wound.​ ​• Flap: The skin adjacent to the wound is elevated and moved to cover the defect. Flaps are typically used for​ ​delicate or difficult areas, under tension, and to minimize distortion.​ ​• Skin graft: Skin from a different area of the body is used to cover the wound. This type of repair can take​ ​longer to heal but can provide excellent results.​ ​• Healing by granulation: The wound is left open and allowed to heal on its own. Certain areas heal very well​ ​by this manner though typically will take the longest to heal.​ ​How is Mohs Surgery Performed?​ ​Mohs surgery is a highly sophisticated procedure performed by a team of medical personnel that includes the​ ​surgeon, nurses, and technicians. It is an outpatient procedure performed under local anesthesia. Your provider​ ​performs Mohs on only one site per day. If you have more than one site for Mohs surgery, we will schedule​ ​separate appointments one week apart for each site to be removed. Your provider makes exceptions for patients​ ​who travel a great distance to come for the surgery. On the day of the surgery, the area of the biopsied skin​ ​cancer is identified together by you and your provider. After the region is adequately numbed, the visible cancer​ ​is scraped away using a curette to better delineate the cancer. A thin margin of tissue is then taken around and​ ​underneath with a scalpel that results in a disc shaped piece of skin being removed. The blood vessels are sealed​

​using an electrocautery and a pressure dressing is applied. The removed tissue is​ ​mapped, oriented and marked with colored dyes for orientation and submitted to​ ​the technicians to process. The specimen is frozen, cut, stained and placed on a​ ​glass slide. Your provider then carefully examines the mapped slides under the​ ​microscope to look for any residual cancer on the margins. This allows your​ ​provider to pinpoint the precise location of any cancerous roots that remain so​ ​extraction can be very precise. Your provider thoroughly evaluates 100% of the​ ​margin including all of the edges and the base of the tissue taken. Unlike​ ​excisions or other types of pathology tests where only 1-2% of the outer margin is​ ​visualized (bread loafing technique), Mohs processing is very unique in that 100%​ ​of the tissue margin is visualized. Combining that with the added precision of the​ ​surgeon reading the pathology slides gives Mohs surgery the highest cure rate.​ ​Each removal and processing of tissue called a “stage” takes approximately 1​ ​hour. If cancer is visualized under the microscope, the surgeon marks that precise​ ​area on the map. The patient is brought back into the procedure room and​ ​additional tissue is precisely removed from the positive region only and submitted​ ​to the Mohs lab for processing. This process is repeated until the margins are clear​ ​of cancer. On the average, it takes one to three “stages” to clear the cancer.​ ​Benefits of Mohs Surgery​ ​Mohs surgery offers the absolute highest chance for cure of most skin cancers​ ​compared to all other therapies. The cure rates for other common techniques used​ ​to treat skin cancer can be as low as 50-70% for previously unsuccessfully treated​ ​skin cancers. Using Mohs techniques with the surgeon as the pathologist,​

​precisely locating tumor roots and excavating those roots leads to cure rates as high as 97-99%, even when​ ​other forms of treatment have been unsuccessful. Besides the highest cure rate, the precision of tissue evaluation​ ​allows the smallest margin possible to be taken, which results in smaller surgery scars, because an unnecessary​ ​margin of healthy tissue is not taken. Those who prefer to know definitively that the cancer is completely​ ​removed before the tissue is repaired (no guessing), prefer Mohs because when tissue is sent to a pathology lab​ ​it generally takes 5-7 days after surgery to find out if the estimated margins were indeed adequate.​ ​Prepare for the Day of Mohs Surgery​

​Please be aware that​​you may need someone to drive​​you home​​after your Mohs surgery depending on the​ ​location of the surgery (near the eye) or if you receive anti-anxiety medications to help your day go smoother.​ ​Most patients are scheduled directly for surgery without a preoperative visit. Your provider will have reviewed​ ​your pertinent medical history including pathology reports before your surgery and a consultation will be done​ ​on the day of the procedure. It is important that you read all the information that we have provided and​​fill out​ ​the Health Questionnaire before your appointment.​​If you would like to see your provider in consultation prior​ ​to the surgery date, we will gladly schedule you an appointment. Please plan accordingly as you will be subject​ ​to activity restriction following your surgery. It is recommended you do not participate in athletic activities for​ ​7-10 days following surgery. Mohs surgery is performed under local anesthesia using injections; you will not be​ ​put to sleep. We​​suggest that you eat your normal​​breakfast​​or lunch unless otherwise specified.​​Take​​all of your​ ​normal medications on the day of surgery, unless instructed to do otherwise​. Please bathe or shower and wash​ ​your hair to minimize your risk of a surgical site infection. If needed, we will provide you with an anti-anxiety​ ​medicine once you have signed the consent form. You will need someone to accompany you to give you a ride​ ​home. This is a requirement if you receive anti-anxiety medicine. Many of our patients are on​ ​blood thinners​ ​that are prescribed by their physician. We do not recommend stopping them without explicit permission from​ ​the prescribing physician. If your prescribing physician has given you guidelines for stopping blood thinning​ ​medicines for a few days prior to minor procedures (surgery or dental procedures), check with your physician​ ​and follow those guidelines. For those on​ ​Coumadin/Warfarin​ ​,​​please make sure that your INR is in the​ ​therapeutic range and please have your most recent INR available for your provider. We request that you stop​ ​taking any prophylactic aspirin or ibuprofen compounds (like Anacin, Bufferin, Advil or Motrin), alcohol,​ ​vitamin E, ginko biloba and garlic pills at least 10 days before your surgery. They can increase your risk of​ ​bleeding during surgery. If your physician has instructed you to take aspirin for any reason other than routine​ ​prevention, please do not discontinue without their permission. Finally, get a good night’s sleep the night before​ ​surgery.​ ​On the Day of Mohs Surgery​ ​When you arrive and first see your provider on the day of Mohs surgery,​​you will need to positively​​identify​​the​ ​biopsy site on which surgery will be performed. The surgical assistant will review your history and prepare the​ ​lesion for Mohs surgery. This is a great time to ask the surgical assistant any questions you might have. Your​ ​provider will review your case and come in to mark the surgery site in surgical ink. You will be asked to sign​ ​consent that you understand the possible risks of surgery (bleeding, pain, infection, recurrence, numbness, scar)​ ​and not doing surgery (cancer grows/spreads). The surgical assistant will numb the area with a local anesthetic​ ​and prep the area for surgery, which includes getting you comfortable, cleansing the surgical area with antiseptic​ ​and placing towels around the operative site. Your provider will then carefully debulk an obvious remaining​ ​tumor and remove a layer of tissue. Any bleeding will be controlled using a cautery or bipolar forceps and the​ ​surgical assistant will bandage your surgical site. Your provider will take the layer of tissue to the laboratory​ ​where it is mapped by orienting it with nicks and tissue dye in preparation for processing. Your provider's​ ​histotechnician will then process the outer margin of tissue, making microscope slides of this true margin. These​ ​slides are stained with hematoxylin and eosin or special stains so that your provider can carefully examine the​ ​microscope slides for any remaining cancer at the margin. This processing takes approximately one hour and is​ ​repeated when the microscope slides show residual cancer at any margin. Typically patients are in our office for​ ​3-4 hours, but longer cases do occur when tumors are very large or have ill-defined margins. You will spend a​ ​significant time in the “Mohs waiting room” during your appointment while tissue is processing. It is a good​ ​idea to bring something to read or work on for the day of surgery. To make your stay more comfortable, we​ ​have a television and wireless Internet access​ ​. You are welcome to bring a friend or family member to your​ ​surgery appointment to accompany you while you wait in the Mohs waiting room,​​but please limit the number​ ​of people accompanying​​you to one person due to the limited space in our waiting room. If you have several​ ​family members or friends at your appointment, we may ask you to wait in a designated area within our​ ​building at the Hulston Cancer Center.​ ​What to Expect After Surgery​

​Once your skin cancer has been completely removed, your provider will discuss repair options with you. Repair​ ​options are individualized, but options include sewing the skin together (simple closure or skin flap), taking skin​ ​from another similar-looking area (skin graft) or actually allowing the wound to heal by itself (granulation).​ ​Your provider will discuss options with you and decide on the best repair. For special wounds, other surgical​ ​specialists can be involved in the repair of your Mohs wound. Typically sutures are removed 7 days after​ ​surgery on the face, and up to 14 days on certain areas.​ ​Mild to moderate post-operative pain usually lasts less than 24 hours and can be controlled using Tylenol​ ​(acetaminophen). Bruising and swelling are common following surgery and usually last for 5-7 days. Applying​ ​ice during the first 24-hours after surgery reduces bruising, swelling and pain. As the surgery site heals, it is​ ​normal for the area to feel like it is tightening. The risk of significant postoperative bleeding is very low. Our​ ​staff will place a pressure dressing on the wound after surgery, which should stay in place for 48 hours. A small​ ​number of patients have some postoperative bleeding as the epinephrine (adrenaline) in the anesthetic wears off,​ ​which usually occurs 1-2 hours after surgery. Applying direct pressure over the dressing for 20 minutes can​ ​usually stop this. For any bleeding that is not controlled after 20 minutes of direct pressure, notify us​ ​immediately.​ ​Numbness is also common at the surgical site because skin cancers are often found around nerves that carry​ ​sensation. This can sometimes become permanent, but most initial numbness improves over 4-6 months. When​ ​skin layers are realigned correctly, sensory nerves slowly grow across the scar minimizing numbness. This​ ​healing process often makes patients feel like​ ​their​​scars are sensitive or itchy​ ​. This is normal and​​can be​ ​expected. Occasionally, a patient’s tumor is large and reconstruction may be easier for the patient if they are put​ ​to sleep by an anesthesiologist. In these cases, your provider will discuss your case with a trusted surgeon for​ ​your reconstruction. Most of the time, your provider will repair your wound on the same day as your Mohs​ ​surgery.​ ​After any surgical procedures you will be left with a​ ​scar​ ​. Every effort will be made to offer the best​​possible​ ​cosmetic result. The scar will often be longer than what you may have anticipated because cancer “roots”​ ​beneath the surface extend beyond what is visible before surgery. The scar may also need to be lengthened to​ ​better fit the contours of the skin. Scars can take a few months or longer to heal completely. The scar can be​ ​minimized by the proper care of your wound. Your provider will individualize wound care after your surgery,​ ​but you should plan on applying ointment to your wound twice daily for 2 weeks and applying a bandage twice​ ​daily for 1 week.​ ​Keeping the area moist after surgery and being disciplined to not let air get to the suture​ ​line will generally give you the best cosmetic and functional result​ ​. Three weeks after surgery, a thick​​or​ ​bumpy scar line can be improved with gentle massage performed for 2 minutes, 2 times daily for 2 months.​ ​Follow-Up Care​ ​After you have a skin cancer, there is a 50% chance that you will develop a second skin cancer within 5 years.​ ​After a diagnosis of skin cancer, your provider recommends that you see a dermatologist at least once per year​ ​for 3-5 years following Mohs surgery.​ ​Frequently Asked Questions​ ​I don't see anything after my biopsy. Do I really need to be treated?​ ​Yes.​ ​Following a biopsy, your skin cancer may no longer be visible. However, the surface lesion that was​ ​removed can represent the "tip of the iceberg." More tumor cells may remain in the skin. These can continue to​ ​grow downward and outward, like roots of a tree. These "roots" are not visible with the naked eye. If they are​ ​not removed, the tumor will likely reappear and require more extensive surgery (see examples of cited studies​ ​below). Tumors that are neglected can spread deeply into the skin and invade nearby structures. On rare​ ​occasions, these cancerous cells can metastasize to lymph nodes and other organs in the body.​ ​Why does my skin cancer need to have Mohs surgery?​

​Mohs surgery has the highest cure rate. It is appropriate for most skin cancers and especially suitable for skin​ ​cancer that:​ ​•Is in an area where it is important to preserve healthy tissue​ ​•Was treated previously and has come back​ ​•Is located near scar tissue​ ​•Is large​ ​•Does not have clearly defined edges​ ​•Is growing rapidly or uncontrollably​ ​•Is of an aggressive subtype (i.e., morphoeic or infiltrating basal cell carcinoma, squamous cell carcinoma)​ ​•Develops in organ transplant or lymphoma patients​ ​Key Points​ ​4. Eat a normal breakfast or lunch before your appointment unless otherwise specified.​ ​5. Bring a book or something to pass the time while you are in the Mohs waiting room waiting​ ​6.​ ​Please plan on spending 4 hours in our office​ ​.​ ​• Although most patients are generally clear and ready to leave well before 4 hours, we cannot predict​ ​the extent of your skin cancer’s roots until we begin surgery.​ ​7. Have a driver escort you after the procedure if needed.​ ​8. You can purchase bandage materials in our office or at your local pharmacy.​ ​9. For convenience,​ ​we sell bandage materials at our​​cost to make them readily available to you​ ​.​ ​1. The night before your surgery,​ ​bathe & cleanse​​the skin.​ ​2. The night before your surgery,​ ​get a good night’s​​sleep​ ​.​ ​3. Take your normal medications, unless otherwise specified.​

​10.​ ​No bending over at the waist for 2 days.​ ​11.​ ​Limited activity for 7 days after surgery.​ ​12.​ ​Plan to return in 7 days for suture removal.​

​Our providers and their staff aim to provide the best experience possible for you on your day of surgery.​ ​Although we operate on critical and cosmetically sensitive areas every day, we realize that you don’t have​ ​surgery every day and any surgery can create anxiety. This educational information is intended to help you​ ​understand what to expect on the day of your surgery and help your day go very smoothly.​ ​Dr. Swann - Mohs Before & Afters​

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