health&healing

Given the steady and significant increase in incidences of skin cancer in recent years, notes Dr. Gregory Wilmoth of Southern Dermatology & Skin Cancer Center in Raleigh, “it’s hardly surprising that dermatology has become a much more surgery-based practice than it was several decades ago. 

“Detecting skin cancers and precancers, of course, has always been a critically important part of our practice,” he notes. “But thanks to developments in micrographic surgery, dermatologists have become the specialists who most often take care of skin cancers—through the whole process of diagnosis, treatment, surgery, and subsequent reconstruction.”

Micrographic Surgery

The key to this transition is the surgical procedure itself, Dr. Wilmoth explains. “Mohs surgery (micrographic surgery), is a surgical technique that differs from other skin cancer treatments in that it permits the immediate and complete microscopic examination of the removed cancerous tissue, so that all ‘roots’ and extensions of the cancer can be eliminated. Consequently, Mohs surgery is broadly recognized as the skin cancer treatment with the highest cure rate—in the range of 99 percent.

“With Mohs surgery,” he explains, “I can remove the cancer in the most minimally invasive way. I’ll take only a 1 mm margin around it, then check 100 percent of that margin to make sure all cancer cells are removed. Once I get the tissue under the microscope, if any part of the margin is positive for cancer cells, I can see exactly where I may need to go back and take a little more out without cutting around the whole area again. In this way, the Mohs technique spares skin, which is of great importance when we’re talking about the face and neck.

“When I say we are able to check ‘100 percent’ of the margin,” adds Dr. Wilmoth, “I mean the entire periphery and the base of the tumor. Our goal is not only to remove all the cancer and reduce the chance of recurrence to the absolute minimum, but also to produce the best possible cosmetic outcome. Mohs permits us to do that.”

Reconstruction

“One of the great advantages of the Mohs procedure,” explains Dr. Wilmoth, “is its efficiency. The information we gather microscopically is available immediately and allows us to decide with the patient how to best repair the surgical site. In fact, in most cases we can typically complete all aspects of the procedure in one step—from removing the tumor to completing the reconstruction.

“I do surgery three days a week—typically about seven Mohs cases. Most of them are done all in one session, in the office, under local anesthesia. This can be especially helpful for elderly patients who may have multiple health problems and are taking multiple medications, and for whom general anesthesia may be riskier.

“With some more complex cases (such as the ones shown here), or in cases that involve a larger area, complete reconstruction may take several sessions. But, most often, we are able to remove the tumor and all cancerous cells, and complete reconstruction in the same session.”

Mohs surgery is the procedure of choice for cancers located in areas such as the nose, eyelids, lips, or hairline, notes Dr. Wilmoth, “because these are areas in which preservation of healthy tissue is critical for cosmetic or functional purposes.

“Sometimes reconstruction involves using skin flaps,” he adds, “and this is another way in which Mohs surgery offers an advantage over other techniques. By keeping those margins as small as possible, and removing as little skin as we can, especially in facial areas, it leaves us with a much smaller area to reconstruct—which ultimately is going to provide better cosmetic results.”

Mohs Surgery: Gold Standard of Care

Developed in the 1940s by a general surgeon, Frederic E. Mohs, Mohs micrographic surgery has increasingly come to be viewed as the gold standard for treating many skin cancers, especially those in cosmetically and functionally important areas such as the face, hands, and feet.

“In fact,” notes Dr. Wilmoth, “micrographic surgery is now recognized by the American Board of Dermatology as an official subspeciality. While the technique itself hasn’t changed significantly, some important developments—such as new, special stains for identifying cancerous cells—have helped increase the efficiency of this surgery.”

 Dr. Wilmoth and his colleague at Southern Dermatology, Dr. Eric Challgren, have extensive experience as well as board certification in micrographic (Mohs) surgery.