Mohs Surgery: Donating a Pound of Flesh Slowly

At Least they Skipped the Zinc Chloride

All in all, I did fairly well with the results of my last six-in-one-day biopsies.  Four were benign, and the prospect of undergoing simultaneous surgery on two didn’t seem insurmountable, so I agreed to a twofer, and scheduled it for last Monday.  One of the two was diagnosed as a basal cell carcinoma, on my cheek to the right of my nose, a simple-looking small pearly bump.  The other was identified as a squamous cell carcinoma, more worrisome due to the potential for metastasis.  This one was on my forehead, just right of center.  These two represented numbers seven and eight of my ongoing issue with skin cancers.  Strangely, all eight have been on the right side of my body.

When it comes to skin cancer surgery, you basically have two options, regular old-fashioned surgery (surgical excision) or the more sophisticated-sounding Mohs surgery.  Given a choice, I opt for Mohs, since it is less invasive and leaves less damage to repair.

Mohs surgery, short for Mohs micrographic surgery, is named for the doctor who first developed the technique, Frederic Mohs.  If the non-Mohs option of surgical excision is used, the surgeon removes visible cancer and adds a comfortable (to him) margin of healthy surrounding tissue in an attempt to insure the elimination of cancer and a possible recurrence.  By contrast, Mohs surgery involves a smaller initial tissue removal followed by microscopic mapping and examination of the excised section while the patient waits.  If the section’s margins are free of cancer, the procedure is over and the wound is closed.  If cancer is still present at any point on the section’s margins, additional surgery is performed, but limited to those areas alone, and again limited in scope.  The second excised section is then mapped and examined microscopically while the patient once more waits.  This process, which might take several surgeries and microscopic analyses, continues until all margins are clear.  For the patient, this could mean a longer morning with multiple anesthetic injections and surgeries, but the results, compared with standard surgical excision, will probably be a smaller wound and scar, coupled with a low probability of recurrence.

In my case last week, when I returned to the doctor after an hour’s wait for results of the first surgery, I found that the forehead squamous cell margins were clear, but not so for the basal cell on my cheek.  No more surgery was required on my forehead, but the doctor had to excise more tissue from the cheek wound.  Another round of anesthetic injections were required, followed by a short second slicing, and then it was back to the waiting room for another hour.  This second attempt also was not completely successful, so a third round was necessary, followed by another, near two-hour, wait for results.  This third time proved to be the charm.  The wound, however, was now quarter-sized, and it took almost an hour to put both holes back together.  As she said goodbye, the doctor pointed out a couple of new spots to ‘keep an eye on.’

This isn’t fun, not near as fun as all that time, long ago, in the sun, but the piper does have to be paid.  If you’ve had Mohs surgery, donated a slow pound of flesh and complained, just be thankful you weren’t one of Dr. Mohs’ early patients.  Back in the 1930’s, when he first performed this procedure, it was called ‘chemosurgery’ because it involved the use of a chemical, zinc chloride.  Mohs had discovered that zinc chloride could ‘fix’ skin tissue for microscopic study, so he first applied a paste of the stuff, allowing excision without bleeding.  This was an involved process that often took days, rather than hours, and caused ‘severe discomfort’ to the patient.  In 1953, Mohs had a patient with a basal cell carcinoma on his eyelid.  To avoid risk to the eye, Mohs skipped the chemical paste step and discovered the results were equally successful.  And with a lot less discomfort.  I’m not complaining anymore.