Mohs Surgery

What is Mohs Micrographic Surgery?

The technique is useful for removing skin cancers that are/have:

  • Large

  • Aggressive pathology including infiltrating growth patterns (root-like extensions that spread into surrounding tissue), or on an area of the body that is conducive to more aggressive growth, such as the center of the face.

  • Recurrent tumors or have failed other therapies, which can be more difficult to remove because they may grow beneath the scar before surfacing, resulting in its true borders being difficult to identify.

  • Located in a place where scarring is a concern, such as on the eyelid, ear, nose or lips.

  • Indistinct margins or borders, making it difficult to see where skin cancer ends and normal tissue begins.

  • Skin cancer that remains after it has been surgically removed, indicated by the initial pathology lab report. (This may sometimes be described as the cancer having "positive margins." In these cases, a scar may exist without other visible evidence of skin cancer.

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With Mohs surgery, the topmost layer of the abnormal skin and visible cancer is removed.

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The removed layer is divided and carefully mapped and inked by the Mohs surgeon, orienting the specimen.

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If necessary, the process is repeated and additional layers are taken until no cancer cells are detected.

Each section is thoroughly examined and your Mohs surgeon will determine if additional layers need to be removed. 

We take incoming referrals for dermatologic surgery including Mohs surgery. We are also available to do a surgical consult to determine what treatment is best suited for your patient. For surgical referrals to Complete Dermatology, please click below to download our referral form.  
 

 

                      Surgical Referral

                        Form 
 

 

You may fax the completed form along with supporting documentation to Complete Dermatology, 808-627-6000, or send it to mohs@complete-dermatology.com. All transmissions will be received into a HIPAA-compliant system.

histology technician
Dr. Flament Mohs Surgeon

After the biopsy layer is taken by Dr. Flament, our certified histotechnician will immediately process the specimen and make slides to stain and give back to Dr. Flament read.

Dr. Flament checks each slide to ensure complete removal of the cancer. If cancer cells remain, another biopsy layer will be taken until the patient is clear and cancer-free.

Post-Surgery Wound Care:

        Mohs micrographic surgery was developed by Dr. Frederic Mohs in the 1930s. The technique involves removing the skin cancer in stages (or layers) and examining the tissue under a microscope to check for cancer. This process is repeated until the microscopic exam reveals clear margins. Clear margins means there are no cancer cells at the edge of the tissue that was removed. This ensures complete clearance of the tumor, while minimizing the margins that are excised. Mohs surgery provides the highest cure rate (98 to 99 percent) of all methods used to treat skin cancer, while also making it possible for our surgeon to preserve as much of your normal skin as possible, thus producing a superior cosmetic outcome and shorter recovery time.

Centrally located in Oahu, we offer a comprehensive Skin Cancer Center that hosts a full surgical unit where a variety of surgical approaches are used, including Mohs Micrographic Surgery. The Mohs technique is used primarily when the preservation of tissue is a priority. This would include skin cancers on the face and difficult to treat areas such as the shins and genitalia. 

 
 

Pre-Surgical Instructions for Mohs Patients

  • Expect to be here all day for Mohs surgery. The Mohs surgical procedure can be extensive, requiring multiple stages and complex repair.

  • Bathe before your surgery as you may be asked to avoid getting the area of your surgery wet until 48 hours after surgery.

  • Do not wash with products that contain alcohol before your surgery.

  • Wash your hair only with shampoo and conditioner. Do not use hair spray or hair gels. These may contribute to a surgical fire.

  • Do not drink alcohol for 24 hours before surgery.

  • Dress comfortably. You may want to bring a sweater or jacket as the waiting room can be chilly.

  • Do not wear makeup in the area of the surgical site.

  • Please eat breakfast and eat regular meals before surgery.

  • Provide a list of your medications to your surgeon. If you have been prescribed antibiotics prior to surgery, please take them as instructed. Take all your regular medications the day of surgery unless otherwise directed by your physician.

  • Do not stop blood thinning medications unless directed by your surgeon. This includes Warfarin, Coumadin, aspirin, Plavix and Pradaxa. Notify medical team if you are taking any of these medications.

  • You will need a driver if your surgical site is close to your eyes. Your visual field may be obstructed by a dressing, which can make driving unsafe.

  • You may want to bring a book, magazine, a computer or other items to help pass the time as there is some waiting during the procedure. You may also want to bring a lunch. Internet access and a few snacks are available in the Mohs waiting room.

  • Notify us if you:

    • Have had a joint replacement in the past two years.​

    • Have artificial heart valve(s)

    • Are taking Warfarin (Coumadin) as this requires a blood test (INR) within one week of surgery.

If you have questions, contact Complete Dermatology between 8 a.m. and 5 p.m. M-F, or you can reach Dr. Flament directly with the number provided on your post-surgical handout.

​​Mohs Surgery: The Most Effective Treatment for Skin Cancer

Mohs "Staging", Step-by-Step Removal of Cancer

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Stage 1

Stage 2

Stage 3

Stage 4

Recovering from Mohs Surgery / Follow-Up

  • Extra Strength Acetaminophen (Tylenol) can be taken as needed to control your pain. Most people have little pain after surgery. Your clinician also may prescribe other pain or antibiotic medications as needed.

  • You may be asked to avoid getting your bandage wet for up to 48 hours after surgery.

  • You may be asked not to swim or be in a pool, hot tub or the ocean until your top stitches are removed (typically 1 to 2 weeks). Avoiding water activities helps to reduce the risk of infection.

  • You may be asked to not participate in any activities that raise your blood pressure or heart rate (any exercise) for 48 hours after surgery. Limiting physical activity reduces the risk of bleeding complications and bruising.

  • There may be other activity restrictions, as determined on an individual basis, that may last for 2 or more weeks.

  • The area surrounding the operative site may be numb. Numbness is not uncommon and can last for many months. Usually felling returns to normal.​

  • You also may experience some skin tightness across the area of surgery. Tightness is normal and will improve with time as healing progresses.

  • Skin heals itself by producing a scar. Scar-free surgery is not possible. The method used to repair your wound will be selected to provide the best cosmetic and functional outcome.

  • Avoid travel for up to two weeks following your surgery in case you need to see your surgeon.

   You will be asked to return to the clinic 1 to 2 weeks after surgery. Your skin will be checked to make sure it is healing well. If you have stitches, they will be removed. Further surgical follow-up will be determined on an individual basis. Your general dermatologist should examine you every 6 to 12 months to check for possible new skin cancer development.

 

Mohs and Surgical Referrals

 
  • Surgery is done in a surgical room at the clinic. Surgery will continue until a cancer-free layer of skin is uncovered. The entire procedure could take several hours, depending on the size and depth of your cancer. 

  • The area around your skin cancer will be numbed using local anesthetic. Once the area is numbed, the first layer of skin will be removed.

  • A dressing will be applied to the area.

 

  • The removed tissue will be carefully mapped and inked by your Mohs surgeon and sent to the lab in the clinic. In the lab, a laboratory technician will prepare microscopic slides.

  • Once the slides are prepared, your surgeon will read the slides under the microscope and determine if there is still any tumor remaining. Most people having Mohs surgery needs 2 to 4 stages. Each stage requires removing the affected area of skin and preparing slides.

  • When your skin cancer has been fully removed and clear margins are seen, a decision is made on the best method for repairing the wound. Possible methods include closing side-to-side with stitches, a skin flap or a skin graft. Some wounds may be left open to heal naturally. The best method is determined on an individual basis.

During Your Surgery

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Sorting Medicine
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