ADVANTAGES OF THE MOHS SURGICAL PROCEDURESome skin cancers can be deceptively large – far more extensive under the skin than they ap-pear to be from the surface. These cancers may have “roots” in the skin, or along blood ves-sels, nerves, or cartilage. Skin cancers that have recurred following previous treatment may send out extensions deep under the scar tissue that has formed at the site. Mohs surgery is specifically designed to remove these cancers by tracking and removing these cancerous “roots.” For this reason, prior to Mohs surgery it is impossible to predict precisely how much skin will have to be removed. The final surgical defect could be only slightly larger than the initial skin cancer, but occasionally the removal of the deep “roots” of a skin cancer results in a sizeable defect. The patient should bear in mind, however, that Mohs surgery aims to remove only the cancerous tissue, while the normal tissue is spared as much as possible.

Skin cancer is the most common malignant tumor in humans. The skin cancers often extend far beyond what is visible on the surface of the skin. If these tumors are not removed, they can invade and destroy structures in their path.

Mohs Micrographic Surgery is the procedure of choice for treating skin cancer pre-dominantly on the face and neck. Mohs surgery allows for the selective removal of tumors with the preservation of as much of the surrounding normal tissue as pos-sible. It offers the highest chance for complete removal of the cancer while sparing normal tissue because it precisely maps the location of the cancer. The cure rate for new cancers with the Mohs procedure can exceed 95%.

THE MOHS SURGICAL PROCEDURETypically, Mohs surgery is performed as an outpatient procedure in the offices of the War-muth Institute. Although the patient is awake during the entire procedure, discomfort is usually minimal and no greater than it would be for more routine skin cancer surgeries.

Step 1: The area to be treated is cleansed, marked, and injected with a local anesthetic. The Mohs surgeon will then remove the visible cancer, along with a thin layer of additional tissue. This procedure takes only a few minutes, and the patient waits while tissue is being processed and examined.

The removed tissue specimen is cut into sections, and marked on a detailed diagram. Frozen on a cryostat, a technician removes very thin slices from the entire edge, and undersurface. These tissue slices are then placed on slides and stained for examination under the microscope.

Step 2: The Mohs surgeon carefully examines the entire undersurface and complete edge of the specimen, and all microscopic “roots” of the cancer are precisely identified and pin-pointed on the Mohs map. Upon microscopic examination, if residual cancer is found, the Mohs surgeon utilizes the Mohs map to direct the removal of additional tissue. Note that additional tissue is removed only where cancer is present.

Step 3: This process is repeated as many times as necessary to locate and remove any re-maining cancerous areas within the tissue specimen.

Step 4: When microscopic examination reveals that there is no remaining tumor, the surgi-cal defect is ready for repair.

Most Mohs cases can be completed in three or fewer stages, requiring less than six hours. However, it is not possible to predict how extensive a cancer will be, as the extent of a skincancer’s “roots” cannot be estimated in advance. Therefore, it is advisable to reserve the entire day for this surgical procedure, in case the removal of additional layers is required.

IMPORTANT REMINDERS from the Warmuth Institute

DO let us know as soon as possible if you need to change or cancel your appointment

DO get a good night’s sleep before the day of surgery

DO eat a nutritious breakfast on the day of surgery

DO continue taking your usual medications unless otherwise instructed

DO wear a comfortable, button-down shirt or blouse

DO shower the night before your surgery and wash hair, so your wound dressing can stay dry

DO feel free to ask questions

DO let our staff know if you take asprin, ibuprofen, warfarin, coumadin, xarelto, plavix or other blood thinners, or antibiotics

DO bring a book to read and snacks or a brown bag lunch

DON’T wear make-up if the procedure will be performed on your face

DON’T consume alcohol 24 hours prior to and 48 hours after surgery

DON’T smoke for at least three days after the surgery

PREOPERATIVE VISITIf you are a new patient, we recommend that you come in for a consultation prior to sched-uling your Mohs surgery. If you take coumadin, plavix or any other blood thinner or if you take an antibiotic before having dental procedures, please bring this to our attention so there is no delay in your surgery.

AFTER COMPLETION OF THE SURGERYDetailed care instructions will be provided to you. You should plan on wearing a bandage for the next 72 hours and avoiding strenuous activity for a week. Most patients report mini-mal pain which can be treated with a combination or Tylenon and Advil, or just Tylenol. You may feel a ‘tightness’ around the wound, numbness (temporary in most cases), or itching. Complete healing takes place over the next 24-36 months. For the first few months, the site may feel thick, swollen or lumpy. There may also be some redness. You will schedule a follow up appointment. Studies have shown that once you develop a skin cancer, there is a strong possibility that others may develop. There are risks, which your doctor will present to you when he or she tells you about your surgery. Some of the usual risks are that the wound may be larger than anticipated. There will be a scar at the site, and we will make every effort to leave the least visible one possible. There may be poor wound healing due to smoking, diabetes, and other diseases. Another risk is the loss of nerve function (numbness). Rarely, wounds become infected. Further risks are excessive bleeding, an adverse reaction to med-ication used, and there is a small chance the tumor may regrow (especially if the tumor is large, or longstanding, or if your immune system is weakened). Please understand these are the exceptions, not the rule.

THE DAY OF SURGERYWe will obtain your written consent for the procedure. This is a good time to ask questions as the Mohs surgeon goes over the detailed alternatives, risk, limitations and side effects with you. photographs will be taken before, and your blood pressure will be recorded. The skin around the skin cancer will be disinfected with an Iodine or techi-care or other disin-fectant solution. Your doctor will then numb the area. This will be similar to the injection you received for your biopsy. It usually takes about 15 minutes to numb the area and re-move the tissue. The tissue will then be processed in our lab. Depending on the amount of tissue, and how fatty the tissue is, processing takes about 1-2 hours. Your wound will be bandaged and you will move to the waiting room. If the examination reveals there is still cancer left, we will go back and remove more. The Mohs technique allows for precise mapping of where the cancer is. Most skin cancers are removed in 1-3 stages.

WOUND HEALING, SCARRING, AND SCAR REVISIONAs with all forms of surgery, a scar will remain after the skin cancer is removed and the surgical area has completely healed. Mohs micrographic surgery, however, will leave one of the smallest possible surgical defects and resultant scars. Often, wounds allowed to heal on their own re-sult in scars that are barely noticeable. Even following extensive surgery, results are frequently quite acceptable. In addition, scars do have the ability, through the body’s own natural healing properties, to remodel and improve in appearance for a 24 to 36 month period. There are also many other techniques available to the patient for enhancement of the surgical area following skin cancer surgery. Depressed or indented scars may be elevated, using a filler, if appropriate. Likewise, a raised or roughened scar may be smoothed, using laser resurfacing or chemical peeling techniques. Skin flaps and grafts also may require a subsequent “touch up” procedure, to further improve their appearance. We will make every effort to leave a barely visible scar.

PERSONALIZED RECONSTRUCTIONAfter the cancer has been removed, a decision is made on the best way to treat the result-ing wound. The best method is chosen on an individual basis. Most of the wound closures are performed in our own office. Other specialists may be used for their unique skills if the Mohs surgeon decides to involve them. We individualize treatment to achieve the best re-sults. These may include:

1. Allowing the wound to heal without any additional surgical repair (“healing by secondary intention”).

2. Wound repair performed by the Mohs surgeon.

3. Repair by the original referring physician.

4. Repair by another surgeon who might have a particular expertise regarding an ana-tomic area, repair type, special equipment, or skill regarding repair of special defects.

5. Adjunct radiation treatment: Sometimes if the cancer appears very aggressive, and the concern is that despite complete removal, a recurrence, or spreading is possible, adjunct raditation treatment is suggested. Underlying conditions contribute to spreading such as chronic lympholytic leukemia, transplant patients and severly immune suppressed patients.

DR. INGRID P. WARMUTHBoard Certified DermatologistMohs SurgeonDr. Ingrid P. Warmuth, Board Certified Dermatologist, FAAD, treats patients from all over New Jersey, Pennsylva-nia and Delaware. In addition to our general dermatology services, Dr. Warmuth is a Mohs Surgeon, Fellow of ASMS and offers cosmetic and laser dermatology treatments and services. Her practice is known as South Jersey’s Body Contouring Center. She prides herself on offering the lat-est, cutting edge technology. Dr. Warmuth and her team are expert injectors, are CoolSculpting University Certified and are proud to be Diamond level providers.

For several years, New Jersey Dermatologist Dr. Ingrid P. Warmuth has been voted “Best of the Best” by the read-ers of The Daily Journal. Most recently, she was voted “Best Dermatologist” by the readers of The Art of Living Well Magazine in their Best of Family Issue! She was also selected as a Top Doc in Dermatology in New Jersey Mag-azine, as well as Top Doc in South Jersey Magazine. Her colleagues and patients know her as an experienced, knowledgeable and caring physician.

I have been seeing Dr. Warmuth for several years and thanks to her I have survived several skin cancers, two of them on the face and one was a mela-noma. She is such a good skin surgeon, I can’t even find the scars anymore. I trust her with my family, and my life. Such a professional, caring doctor. Her staff is so helpful as well. They are just great. Thanks to all of you. - C.A., 45

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Your appointment for the Mohs Procedure is scheduled for:

at our Surgical Center located at 399 Front Street, Elmer, NJ 08318

Elmer | Salem | Swedesboro856.358.1500 • www.warmuthinstitute.com