Quick Links

Learn more about the cosmetic facial surgery procedures our office provides to patients in Staten Island, New York (NY):

Surgical Procedures

Learn more about the cosmetic facial and oral surgery procedures we provide to patients in Staten Island, New York (NY):

>>Return to Top

Moh's Surgery

cosmetic facial surgery • staten island, ny

In the 21st Century, Mohs Micrographic Surgery represents the state-of-the-art treatment for skin cancer by providing the highest cure rate, minimal sacrifice of normal skin, and smallest possible scar. The origin of Mohs Micrographic Surgery dates back to the 1930's when Dr. Frederick Mohs at The University of Wisconsin was researching a way to remove complicated skin cancers unresponsive to traditional therapies such as standard excisional surgery, cryosurgery (freezing), electrodessication and curettage (scraping and burning), and radiation therapy. Mohs Micrographic Surgery is Dr. Marmur treatment of choice for complicated skin cancers including basal cell carcinoma, squamous cell carcinoma, melanoma in situ and others that have one or more of these characteristics:

Located on the face, ear, eyelid, lip, and scalp
Poorly demarcated (unable to determine edges of the tumor with the naked eye)
Recurrent (failed prior treatment)
Incompletely removed (positive margins after initial removal)
Large (over 2 cm in diameter)
Aggressive histologic features (morpheaform, perineural invasion, poorly differentiated)

The American College of Mohs Micrographic Surgery and Cutaneous Oncology (www.mohscollege.org) is the official organization responsible for training Mohs surgeons and maintaining the standard-of-care in the specialty of Mohs Surgery. To become a member of this organization and be known as a Mohs surgeon, a special one to two-year fellowship following a dermatology residency is required. Only a limited number of dermatologists are trained each year to be Mohs surgeons to maintain the highest level of competence in the specialty. Make sure that your Mohs surgeon is fellowship-trained and a member of the Mohs College.

In summary, the use of Mohs Surgery significantly increases the chance of complete cure and reduces the unnecessary sacrifice of surrounding normal skin. This minimizes the size of the hole, makes it easier to repair the defect, and will result in a smaller scar.

Basics of Mohs Micrographic Surgery--How It Works

Mohs Surgery is a complex procedure combining surgical excision with immediate microscopic examination of the entire tissue specimen margin by frozen tissue processing techniques right in the office while you wait. In addition to Dr. Marmur , who serves as the Mohs surgeon and pathologist, histotechnologists are employed to process, cut, and stain the tissue specimen for proper histologic study. Mohs surgery consists of four steps:

Numbing the skin with a local anesthetic called Lidocaine, marking the skin to create a map, and then surgical removal of a thin layer of skin containing the tumor in the shape of a pie.
Dividing the pie-like specimen into slices that are numbered, mapped, color-coded in the exact same orientation as the map on the patient's skin and a paper map that will be used during the microscopic examination.
The tissue slices are frozen and sectioned into tissue paper thin slices that are placed on glass slides and stained in our Mohs lab contained by our own staff of four histotechnicians.

Dr. Marmur examines each section under the microscope to determine if tumor tentacles are left behind in the skin. The tissue is oriented on the slide so that the border of the tissue or the pie crust is examined. This allows Dr. Marmur to examine 100%of the margin just like he was looking at the entire pie crust of the pie. The filling of the pie or center of the tissue specimen is not examined because the tumor has already been diagnosed by the prior biopsy and the center of the specimen is not helpful for margin control. If the tumor is removed completely, the skin defect is ready to be repaired. If the specimen is positive for residual tumor, steps 1 through 4 are repeated until the skin is clear of tumor (see diagram

This detailed examination of 100% of the margin by Mohs Micrographic Surgery differs from all other pathology techniques. If you have a skin cancer excised by a physician in the office or hospital, the tissue specimen will be sent to a pathology laboratory for processing and examination by a pathologist. The standard pathology techniques examine only 1% or less of the margin (pie crust). If this 1% is clear of tumor, the pathologist and surgeon assume that the other 99% of the margin is also clear. This approach might work well if skin cancers grew into the skin in a symmetrical manner like a sphere, however most complicated skin cancers grow in an unpredictable manner with tentacles growing in eccentric patterns that may wrap around nerves or track along cartilage planes.

Therefore, eventhough a pathology report indicates clear margins, there may be tumor tentacles left behind on the 99% of the margin that was not examined. This incomplete examination of the margin is the most common cause for a tumor growing back and requiring another surgery. Mohs Micrographic Surgery does a better job of preventing recurrences because the entire margin is examined. Recurrent tumors can be very destructive as demonstrated in Part II and Part III of the nasal reconstruction photos below. Please click on the following link to see how the tissue is processed differently and how this impacts the cure rate and size of the skin defect.

The Mohs Surgery technique allows Dr Marmur to examine 100% of the surgical margin (or pie crust) and, if tumor is still present, pinpoint the exact location of the residual cancer. This enables him to return to the treatment area and selectively remove another layer of skin from the positive area only. This minimizes the amount of normal skin that is removed and therefore creates the smallest possible defect in the skin. Guessing the location of residual tumor in the skin is completely eliminated with Mohs Surgery. Since many of the skin cancers removed with Mohs Surgery are complicated, multiple stages are often required to clear the tumor. Please be patient!!! Examination of each of your stages takes up to 60 minutes. If multiple stages are taken, the Mohs procedure can take up a good percentage of the day. Usually you have been warned if a prolonged procedure is anticipated. The vast majority of this time will be spent sitting in the waiting room watching television or reading a book or magazine.

Advantages of Mohs Micrographic Surgery

Procedure performed from start to finish by a skin cancer expert
Highest cure rate available for skin cancer
Visualizes 100% of margin of excision vs. 1% with normal pathology
Smallest amount of normal skin is removed
Preserves cosmetics and function of treated area
Smallest possible defect results in smallest possible scar
Surgery and microscopic examination by the same person
Reconstruction performed immediately after tumor removed
All done under local anesthesia in the office

Reconstruction of the Mohs Micrographic Surgery Defect

When the final stage of Mohs Micrographic Surgery is found to be free of tumor, your skin cancer has been removed with a 99% cure rate for primary tumors and over 95% for recurrent tumors (previously treated but then came back). You are left with a skin defect that has clean margins (free of skin cancer). The Mohs Micrographic Surgery phase of your procedure is completed.

The next phase of your procedure is the skin reconstruction. The reconstruction phase is where Mohs surgeons and other reconstructive surgeons can differ significantly in their approach and final results. Dr. Marmur works closely with Drs. David Hoffman and Mark Stein, experts at skin reconstruction, especially of the nose, ears, lips, and facial defects, who will utilize highly advanced reconstruction techniques to provide a natural cosmetic result with minimal to no visible scarring.

Drs. Hoffman & Stein offer several options for the repair of the Mohs defect:

allow the defect to heal in on its own
close the defect in a straight line
utilize a flap closure
utilize a graft closure
utilize a combination of the above steps.

A flap repair involves the mobilization and stretching of tissue adjacent to the defect. A graft consists of the removal of skin from a distant site (i.e. in front or behind the ear) and replacing it over the defect. Unlike other reconstructive surgeons, Drs. Hoffman & Stein relie primarily on unique flap reconstructions to provide the best cosmetic result. Adjacent skin used in the flap repair matches the thickness, color, and texture of the missing skin, whereas the graft skin removed from another facial area will not match exactly in thickness, color, or texture.

Allowing the defect to heal without reconstruction can take 3 to 12 weeks of daily wound care and produce unpredictable scarring ranging from excellent to an unacceptable cosmetic result. Drs. Hoffman & Stein favor flap reconstruction with suture removal after one week with a predictable scar over allowing the defects to heal in on their own. Linear closure is preferable in certain facial regions, however flap repairs that create broken and geometric scars (Z-shaped, L-shaped) provide a superior cosmetic result. Linear scars that cross facial creases are much more obvious than broken lines and are more likely to spread over time.

Another important component of advanced reconstructive surgery is the meticulous suturing of the skin. Drs. Hoffman & Stein emphasize the use of buried or subcutaneous sutures in his closures. These buried sutures dissolve over a one to three month period and allow the skin edges to form a strong bond that will prevent delayed spreading of the scar (commonly seen in wounds closed with only top or superficial sutures). When placed properly, buried sutures will completely close the wound edges so that superficial sutures can be used to perfectly align the skin edges. Well-aligned skin edges seen on day one will result in a barely visible scar down the line. Since the wound tension is handled completely by the buried sutures, the top sutures can be removed in one week or less and will not cause the "railroad track" scars commonly seen with inferior stitching techniques. Scars typically heal over a 12 month period of time, however his suturing techniques can produce remarkable resolution of scars within six weeks or less.

To see examples of Drs. Hoffman & Stein’s reconstruction techniques and results, click on the following links:

Please note:

These photos of surgical defects following Mohs Micrographic surgery are real and unaltered. Do not view them unless you are prepared to see graphic images including skin wounds and surgical procedures.

The objectives of these slide shows are to introduce you to Drs. Hoffman & Stein unique facial reconstruction procedures and provide you with a greater understanding of the final results that he can achieve despite significant tissue loss.

These cases do not represent the typical, small, and simple reconstructions representative of the majority of Mohs surgery patients. Instead, they illustrate some of the larger defects and more advanced and proprietary reconstruction techniques. They do not necessarily represent your skin cancer, defect diameter or depth, or the reconstruction choice and outcome.

Reconstructions of the...

Nose
Ear
Lip
Eye
Chin
Forehead
Cheek
Scalp

How To Prepare For Your Surgery

1. Do not take any aspirin or aspirin-containing products for at least 3 weeks prior to your surgery. Aspirin thins the blood. Also, do not take other anti-inflammatory pills, headache and cold remedies, or Alka-Seltzer. If your physician recommended that you take the aspirin, please check with him/her before stopping your medication. Please take Tylenol for a headache or pain. In addition, if you take high doses of Vitamin E, please stop it at least 14 days before the procedure. Coumadin, only if your doctor approves, should be discontinued 3 days before surgery.

2. If you require antibiotic prophylaxis before dental procedures or other surgery, take your first dose of antibiotics 1 hour before coming to the office for your Mohs surgery. If you do not have a prescription at home, be sure to call us at least 3 days in advance of your surgery date so that a pharmacy can be called.

3. If your skin cancer is located in the center of your face, eyelid, or eyebrow area where a bandage will block your vision or impact your ability to wear glasses, please have someone available to drive you to and from the office. Because of limited space, you may have one family member wait with you on the day of surgery. This will help to ensure your comfort as well as that of the other patients having surgery on the same day.

4. Eat a normal breakfast or lunch on the day of surgery. If you wish to bring your own lunch or snacks, we have refrigerator space available for you.

5. Please wear comfortable clothing. Make sure that your shirt buttons in the front and does not slip over your head. No one-piece outfits.

6. Please take a shower and wash your hair on the morning of the day of surgery. Do not apply makeup (if the skin cancer is on your face), perfume, aftershave, or cologne.

7. Take all of your routine medications, as you normally would EXCEPT any of your medications that we have told you to stop (i.e. aspirin or Coumadin).

8. If you are unable to keep the scheduled appointment for surgery, please contact our office at least 48 hours in advance to reschedule your surgery appointment.

What To Expect On The Day Of Surgery

Pictorial Introduction to Our Office, Mohs Surgery Staff, and Laboratory (meet our staff and tour the office and Mohs laboratory prior to coming to the office.

After you arrive in the office, one of our nurses will greet you and take you to the treatment room where the Mohs procedure will be performed. They will take your blood pressure and ask about your medications and allergies.

Dr. Morganroth will be in to greet you before the start of the procedure and answer any last minute questions. Please let us know if there is anything we can do to make you feel more comfortable (i.e. change the chair position, etc.).

First, Dr Marmur will use a small needle to inject a local anesthetic (Lidocaine) to numb the skin. This feels like a bee sting and lasts only a few seconds. This is the only part of the procedure that is uncomfortable. The numbing medication lasts a few hours, however if additional injections are needed later, these are usually painless or much less painful.

After the area is numb, Dr. Marmur will remove a thin layer of skin affected by the cancer. This is called Stage I and represents the first layer of skin that is mapped, divided, and color-coded. After Stage I is removed, an electric needle is used to stop any bleeding. The wound is bandaged with gauze and you will return to the waiting room or stay in the procedure room. While you are waiting, ask for coffee, read a book or magazine, or chat with other patients. Over the next hour or so, Dr. Marmur and the histotechnicians are busy processing the tissue and examining the stained tissue sections with the microscope. Please be patient since this technique requires meticulous care.

If the microscopic examination reveals that there is still skin cancer behind, Dr Marmur will repeat the procedure as soon as possible. This second layer is called Stage II. Because Stage I was divided, numbered, and color-coded, Dr. Marmur can determine exactly where residual skin cancer is left behind. Stage II will consist of a layer of skin that corresponds to the map created from Stage I. Therefore, additional tissue is removed only from those areas still affected by skin cancer. The average number of removals required is two to three stages. Fortunately the Mohs procedure can be completed typically in less than a half-day and is on an outpatient basis.

Once Dr Marmur is confident that the skin cancer has been completely removed, he will discuss the options to repair the wound. Most often the wound can be closed in a linear fashion with stitches. This turns the circular hole in the skin into a fine straight line (scar). In other cases, a more complex procedure known as a flap or graft may be required to provide the best possible cosmetic result. This decision will depend on the wound size, depth, and location. If the wound is stitched up, the stitches are removed typically one week later. For more information regarding the reconstruction process, please see the section on reconstruction of the defect.

Wound Care Instructions

This instruction sheet is designed to help you care for your surgical wound following Mohs Surgery and any reconstruction of your skin defect.

Supplies that need to be purchased prior to surgery:

Polysporin antibiotic ointment
Telfa dressing
Paper tape

All of these items are over-the-counter and are available in drug stores and pharmacies.

WOUND CARE

Keep the post-operative bandage in place until showering the next morning.
Before showering, remove the bandage and discard it the trash.
Cleanse your incision with soap water (not hydrogen peroxide) to remove any drainage and crusting.
Pat the wound dry and apply a generous layer of Polysporin ointment to the incision.
Cover the Polysporin with a Telfa dressing cut into the shape of the wound.
Tape the Telfa dressing in place with paper tape.
Continue this wound care once daily until you return for suture removal.

PRESCRIPTION MEDICATIONS

Continue your regular medications as you normally would.
Restart your aspirin, aspirin-containing products, Coumadin, and Vitamin E (these were stopped before surgery) on the day after surgery.
In the first 24 hours after surgery, take TYLENOL, not aspirin, for pain.

ACTIVITY LEVEL FOLLOWING SURGERY

Spend the first day post-surgery relaxing.
Keep your head elevated during the first few evenings with a couple of pillows.
If surgery was performed around the eyes, apply ice packs during the first 48 hours to minimize swelling. Forehead, cheek, or eyelid repairs may result in a black eye(s)
Heavy lifting and exercise are not allowed until after the sutures are removed.
Showering can be started the morning after surgery. Bathing is allowed if the incision site is not soaked for more than one minute at a time. Pat the wound dry after leaving the shower and reapply the polysporin and bandage. Swimming is not allowed until after the sutures are removed.

Potomac Surgical Arts, P.C.

Oral & Maxillofacial Surgery

Lansdowne, Virginia

804-555-5555