Mohs surgery is considered the gold standard for removal of many types of skin cancer.
This method spares the most amount of normal tissue and has the highest cure rates for many non-melanoma and melanoma skin cancers. It’s the standard of care in non-melanoma skin cancers and is commonly used in the treatment of some melanomas.
It is minimally invasive and leaves patients highly satisfied with their cosmetic outcome. The procedure is named after Dr. Frederic E. Mohs, who developed the Mohs technique in 1938. However, the procedure has evolved over time, and the current technique uses fresh frozen tissue to give a “same-day” cure.
How Does Mohs Surgery Work?
In this outpatient procedure, the surgeon serves as both pathologist and reconstructionist. The surgeon first removes the clinically apparent tumor, then cuts out the base of the tumor and a very thin peripheral margin of skin (1-2 mm) around the tumor.
This thin layer of skin is processed and examined to see if the margins around the tumor are clear or if any tumor remains. If any tumor remains, the surgeon repeats the process to clear only the cancerous areas while leaving any normal skin.
Mohs’ effectiveness is due to its evaluation of 100% of the margins around a tumor. Most cancer recurrences from other treatment modalities come from tumors that were not completely removed. Even with other types of histopathologic evaluations typically done in the operating room by plastic and general surgeons with pathologists, only a small proportion of the margin is evaluated.
With the Mohs technique, surgeons, who are also the pathologists, see 100% of the area around the tumor histologically which allows them to clearly define irregular borders of the tumor and remove all affected areas. This dramatically lowers the likelihood the cancer will return.
What Cancers Are Treated By Mohs Surgery?
Mohs surgery is an effective way to treat tumors with extensions under the skin’s surface. It’s been found as a highly successful way to treat a variety of high-risk non-melanoma skin cancers such as:
- Basal cell carcinoma
- Squamous cell carcinoma
- Dermatofibrosarcoma protuberans
- Atypical fibroxanthoma
- Merkel cell carcinoma
- Microcystic adnexal carcinoma
- Sebaceous cell carcinoma
- Extramammary Paget disease
- Trichilemmal carcinoma
- Mucinous carcinoma
- Eccrine carcinoma
Also, Mohs surgery is increasingly used as a treatment option for melanoma, depending on the location and aggressiveness of the specific type of melanoma.
Mohs surgeons have found the procedure to be especially effective for patients with:
- Head and neck tumors
- Tumors on areas that needed tissue sparing such as the hands, feet, genitalia, and shins
- Tumors with an aggressive histologic appearance
- Tumors greater than two centimeters off the head and neck
- Tumors on immunosuppressed patients, including those with organ transplants, leukemias/lymphomas, autoimmune conditions, and on immunosuppressive medications
What Should I Expect During Mohs Surgery?
Mohs surgery is an outpatient operation that usually only requires the use of local anesthesia. The duration of the surgery depends on the size of the tumor, the anatomic location, the aggressiveness of the tumor, the number of additional layers needing removal, and if reconstruction is needed.
Plan on reserving the day for your surgery, since it is difficult to know how long the surgery will last.
The surgeon will prep the area, remove the tumor, and then spend 15-60 minutes analyzing the tissue to see if any additional areas need to be removed. If so, they surgeon will remove additional areas and examine the tissue again.
This will continue until all cancer-affected areas are removed. If needed, the local anesthesia can be re-administered to keep you as comfortable as possible.
When you are cancer-free, the surgeon will reconstruct the area as necessary.
How Soon Will I Recover From Mohs Surgery?
Most patients recover quickly from Mohs surgery. After your procedure, you’ll receive specific verbal and written instructions about the days following your surgery. In general, you’ll need to leave bandages on for 24-48 hours. After you remove the bandages, clean the wound with a vinegar solution and apply Vaseline regularly. For some flaps and grafts, more extensive care may be needed.
For surgeries around the eyes or upper nose, there will likely be swelling immediately following the surgery. These patients should not plan to drive themselves for the remainder of the day due to limited visibility from swelling or bandage.
Also, patients must limit physical activity for 2-4 weeks to allow for maximum healing. This helps prevent a rise in blood pressure that can cause hematomas and restrict movements that can pop stitches.
Sutures can usually be removed from the head or neck within 5-7 days. Sutures on the trunk and extremities may remain for 2 weeks.
Aesthetic and functional recovery depends on the extent of your surgery and tumor. Most people are happy with their results within one month of their surgery, but full maturation of the aesthetic appearance may take up to a year.
How Much Does Mohs Surgery Cost?
Mohs surgery costs change depending on the extent of the surgery and reconstruction and the patient’s insurance coverage. However, there have been studies to try to determine the averages of how much Mohs surgery costs compared to standard excisions, radiation, and cream treatments. These studies compare treatments of similar-sized tumors and consider the likelihood additional treatments in the event of recurrence. However, these studies typically do not include reconstructive costs, which may vary depending on the extent of the surgery.
On average, Mohs surgery can cost anywhere from $804 to $2000 (without insurance), but the cost may vary greatly depending on the patient’s situation and the extent of the surgery. For example, patients may need multiple stages or a complex reconstruction which pushes the cost much higher.
Remember, this is an average and may not take reconstruction in mind. The reconstruction is mainly done by the Mohs surgeon, so it’s typically performed on the same day – but the cost of reconstruction is NOT bundled into the cost of the actual Mohs tumor removal.
Mohs surgery is conducted by one surgeon who also acts as the pathologist and reconstructionist. There is typically no anesthesia, hospital, or surgical center fee. Since Mohs surgeons evaluate the entire tumor margin, the decreased risks of recurrence and metastasis also spare costs for secondary and additional treatments.
Let’s compare that to other treatments:
Excisions in office cost about $1000-1200. However, you have additional costs if there is recurrence.
If an excision is done in an operating room or an ambulatory surgery center, costs can increase to about $2500 plus the anesthesia fee and the cost of postoperative care, making an excision more expensive than Mohs.
There may also be a need for a pathologist and a reconstructionist, each of whom will charge additional fees. In some cases, the use of a multidisciplinary approach by the Mohs surgeon with other doctors
For certain skin cancers, topical treatments are an option. Imiquimod cream is a treatment cream for basal cell carcinoma and other non-melanoma skin cancers. It costs about $945 for the recommended six-week supply of medication.
Radiation is priced based on factions, and costs vary. In a 2009 study, costs ranged from $2500 to $3400 for the amount of radiation needed to treat most skin cancers.
All in all, costs should not be the most important factor in selecting the right treatment option for you. Consider the overall experience, value, and final outcome.
Contact us for more information or to schedule your skin cancer screening.