A Handbook for Patients

Day of Surgery

1. Eat a light breakfast.

2. Wear comfortable clothes.

3. Bring a craft or a book.

4. Bring a relative or friend.

5. Drink NO alcoholic beverages for 24 hours prior to surgery.

6. Reserve the ENTIRE day for this procedure to allow for removal of multiple layers (as required) and time for appropriate closure.


Please discuss with Dr. Byrd or let our office know prior to your surgery:


If you are on any prescribed blood thinner (i.e.: Coumadin) we will need a recent INR (blood test)
If you have Mitral Valve Prolapse
If you have had a joint replacement
If you have a Pacemaker, or Internal Defibrillator
If you have any major medical issues (i.e. diabetes, heart problems)


Approximately 60 years ago, Dr. Frederic Mohs, Professor of Surgery at the University of Wisconsin, developed a technique (known as the chemo-surgery) to remove skin cancers, which provided patients with an excellent chance for cure. However, because this method is time consuming and requires highly specialized training and personnel, few medical centers in the United States are equipped to offer such treatment. The large number of cases which have been cured clearly demonstrates that MOHS surgery is a highly successful method of treatment for skin cancer.

This booklet attempts to answer some of the questions you may have as a patient concerning this way of treating skin cancer. Should you have further questions, please do not hesitate to ask us.

David R. Byrd, M.D.

David R. Byrd, M.D.

Board Certified Dermatologist and Dermatologic Surgeon. Diplomat of the American Board of Dermatology.

Fellow of the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Dr. Byrd completed his residency and fellowship in Dermatologic Surgery at the Mayo Clinic in Rochester, Minnesota.

Affiliate with William Beaumont Hospital, Troy and Crittenton Hospital, Rochester.

He is published and presented extensively nationally as well as internationally with regard to skin care and maintains his focus to obtain the best care to his patients and their skin.

We are dedicated to making our patients feel comfortable and informed about their experience with us. Our well trained staff and qualified physician is ready to assist you with any of your medical needs and skin concerns.

What is skin cancer?

Cancer is abnormal tissue which grows at an uncontrollable and unpredictable rate at the expense of normal tissues. In the skin, there are three main forms: basal cell carcinoma (or epithelioma), squamous cell carcinoma, and malignant melanoma. The names refer to the cell types from which these cancers are derived.

Is it dangerous?

The most common types of skin cancer are basal cell carcinoma and squamous cell carcinoma. Both types enlarge from the point where they first occur and usually do not spread (metastasize) to distant parts of the body. If not completely removed, both frequently will invade and destroy structures in their paths. Compared to other forms of cancer, these types of skin cancer are generally recognized in their early stages and are therefore more easily cured. Extensive squamous cell carcinoma has a potential to spread to other organs (metastasize).

Malignant melanoma, on the other hand, may be life-threatening if not treated early. It usually appears as a brownish-black spot or bump on the skin which enlarges and sometimes bleeds. Some melanomas arise in moles which have been present for many years.

What causes skin cancer?

The cause of skin cancer, like other forms of cancer, is not completely known. Excessive exposure to sunlight is the single most important factor associated with the development of these skin cancers which develop most commonly on the face and arms (the most sun-exposed parts of the body). Fair-skinned people develop skin cancer more frequently than dark-skinned people. Skin cancer, unlike cancer of other organs is rare in African-Americans. Cancers of the skin are more common in the southern United States.

Skin cancer also tends to be hereditary and occurs very frequently in certain ethnic groups, especially those with fair complexions such as Northern Italians, and Celtic (especially Irish). The Boston Irish, even though they live in the Northern United States, have a higher rate of skin cancer than Italians living in southern Italy, i.e., there is an inherited tendency.

Other possible causes of skin cancer include x-rays, trauma and certain chemicals. There are numerous studies going on to identify these and other possible causes.

How does skin cancer start? How does it grow?

Skin cancer begins in the uppermost layer of the skin and grows downward with roots and also sideways on the surface of the skin. Unfortunately, these extensions cannot be directly visualized. Therefore, what is apparent to the naked eye on the surface of the skin may actually be only the “tip of the iceberg.”

How may skin cancer be treated?

There are several methods of treating skin cancer, all highly successful in the majority of patients.

These methods include excision (surgical removal) and suturing (sewing) curettage and electrodessication (scraping and burning with an electric needle), radiotherapy (x-ray), cryosurgery (freezing), topical chemotherapy (chemical destruction), and chemosurgery or MOHS surgery (microscopically controlled excision). The method we use depends on several factors, such as the location of the cancer, its size and previous therapies applied to the skin cancer.

What is MOHS surgery?

The term MOHS Surgery refers to a highly specialized procedure for the total removal of skin cancers. MOHS, as an acronym, stands for Microscopically Oriented Histographic Surgery.

How is it performed?

As originally described, MOHS surgery involves the surgical removal (or excision) of the skin cancer under a local anesthetic. This excised tissue is prepared by frozen section and examined under the microscope. Before this tissue is examined, it is marked with colored dyes to distinguish top from bottom and right from left. By doing this, we are able to pinpoint the exact location of any remaining tumor during the microscopic examination. If more cancer is found the entire procedure is repeated, but only in the area of the remaining cancer.

How long does it take?

Total removal of a skin cancer, which may involve several surgical sessions, is usually completed in one day. After the surgery, a decision is made as to the best way to manage the wounds created by the surgery. This will be discussed later.

How effective is MOHS surgery in the treatment of skin cancer?

Using the MOHS technique, the percentage of success is very high, often 95-99%, even if other forms of treatment have failed. Therefore, with this technique, an excellent chance of cure is achieved. However, no one can guarantee a 100% chance of cure.

What are the advantages of MOHS surgery?

Some skin cancers can be deceptively large- far more extensive under the skin then they appear to be from the surface. These cancers may have “roots” in the skin, or along blood vessels, nerves, or cartilage. 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 MOHS surgeon can pinpoint with the microscope the areas where there is cancer and selectively remove tissue only from those areas. In this way, the skin cancer is traced out to its roots with little guesswork involved, which results in (1) the removal of as little normal tissue as possible, and (2) the highest chance of curing the patient. Other forms of therapy frequently have only a 50-75% chance of success in curing skin cancers that have had previous treatments that failed.

Will the surgery leave a scar?

Yes. Any form of surgery will leave a scar. However, the MOHS procedure tends to minimize this as much as possible.

Will my insurance cover MOHS surgery?

Most health insurance policies cover the total cost of MOHS surgery and the reconstruction of the resultant surgical area. Ever individual policy is different. Please contact your insurance company directly to discuss your individual payment benefits. If you have any additional questions regarding costs please contact our billing department.

Scheduling your surgery

Every skin cancer is different, and because of the high demand for MOHS treatment, careful scheduling is necessary. A suitable date for surgery that is mutually acceptable will be arranged for as early a time as possible.

When a patient has been referred to us, usually a biopsy (removal of a piece of tissue) has been performed, and we have the pathology report that states what type of skin cancer is present. If we don’t have this information, we will perform a biopsy at the initial visit. Because not all skin cancers are alike, we need to know exactly what type you have before we can decide how to best proceed.

Photographs may be taken before treatment, as well as immediately after surgery and after healing. These photographs become part of your medical record and may be used for teaching purposes.

Will I need to be hospitalized?

All surgeries are performed at Rochester Skin Cancer and Surgical Center with rare exceptions.

How should I prepare myself for MOHS surgery?

Try to get a good nights rest and eat a light breakfast. If you’re taking any medication, take it as usual unless we direct you otherwise.

It’s a good idea to bring a book or magazine with you on the day of surgery. The procedure may take a full day, most of which you will spend in the waiting room waiting for your tissues to be examined. You should bring a lunch or snack with you.

Reserve the ENTIRE DAY for this surgical procedure, in case the removal of multiple layers is required.

Optional preparation - 3 days prior

Using homeopathic Arnica Montana tablets (taken orally as directed on the bottle) for three days prior to surgery and after surgery can help reduce swelling and bruising. Mint, methanol and caffeine can reduce the efficacy of the Arnica and should be eliminated as much as possible.

Arnica Montana can be found at some health food stores.

Should someone come with me on the day of surgery?

Yes. It is recommended that you have someone drive you home- and it may be pleasant to have company while sitting in the waiting room.

How long does the surgery take?

Each step (or stage) of the surgical procedure takes and average of 2 to 3 hours. The initial surgical procedure is approximately 30 minutes; the time may be longer in extensive cases. However, after the tissue removal it takes approximately 2 hours for the slides to be prepared for the physician to complete and complex microscopic examination. Several surgical stages and microscopic examinations may be required. If you have more than one surgical area, the time involved will be more extensive.

Does it hurt?

A local anesthetic, usually Lidocaine is injected around the skin cancer to numb the area. A burning sensation is felt during the injection of the anesthetic. The surgery does cause slight discomfort.

What happens on the day of surgery?

Appointments for surgery are usually scheduled early in the day. This allows us to continue the surgical steps throughout the entire day if necessary.

The nurse will escort you to an operating room where a local anesthetic will be used to numb the skin so that you will feel little discomfort. Be sure to inform Dr. Byrd if you do experience any pain during surgery.

The next step is for the surgeon to remove a layer of skin involved by the cancer. After this tissue has been carefully removed, bleeding is stopped with a machine called cautery, which generates heat. You may feel this slightly. Before you leave the treatment room the nurse will dress your wound, and by the time you get to the waiting room the removed tissue will be in the laboratory where it is being prepared for microscopic examination.

The most difficult part of the procedure is waiting for the results of the surgery. It usually takes about 2 hours to prepare the slides from the removed tissue, although sometimes it may take longer. Please remain in the waiting room during this period.

If examination of the slide reveals that your tissue still contains cells of skin cancer, the procedure will be repeated as soon as possible. Several surgical excisions and microscopic examinations may have to be done in one day, and seldom is it necessary to have a patient return the following day for additional surgery.

How many surgical sessions are there?

The average number of surgical sessions is two or three, so most patients are finished by mid-day. In case you must stay longer, bring a light lunch with you. Please- no alcoholic beverages. Alcohol dilates blood vessels and may promote bleeding.

Will I have pain after the surgery?

Most patients do not complain of pain. However, pain is an individual phenomenon and if you’re uncomfortable we recommend taking 2 tablets of Extra Strength Tylenol every 4 hours. Avoid aspirin-containing compounds (such as Anacin, Bufferin or Ibuprofen) as these may produce bleeding. We also recommend stopping Vitamin E and garlic supplements.

You may experience some bruising and swelling around the wound, especially if the surgery is performed near the eye area.

What about bleeding after the surgery?

Occasionally there is bleeding following surgery. If this occurs place steady, firm pressure over the wound as close as possible to the area that is oozing blood. Apply the pressure continuously for 20 minutes (timed). Do not lift the bandage to check on the bleeding. If bleeding persists after 20 minutes of steady pressure, notify our office or go to the nearest hospital emergency room.

What are other possible complications?

All wounds develop a small, surrounding halo of redness which disappears gradually. Severe itching with extensive redness usually indicates sensitivity to the ointment used to dress the wound or a reaction to adhesive tape. You should call our office if this develops.

Swelling is very common following MOHS surgery, particularly when it is performed around the eyes. All wounds show a moderate amount of swelling. Usually this is not a problem. You will be instructed to apply ice to the area.

All wounds normally drain which is why we may insist on frequent dressing changes. Infection is unusual.

Other possible complications include mild bleeding during the operation and a reaction to the local anesthetic used, the latter being a very rare problem.

What’s the next step after MOHS surgery has been completed?

When we have determined that the skin cancer has been completely removed, a decision is made about the wound created by the surgery:

1. The wound may be allowed to heal by itself.

2. For small post-surgical sites, direct closure by suturing the sides of the wound together may be possible.

3. In certain areas of the body, there is very little tissue that can be stretched for coverage of a wound. In this case either a skin graft or a skin flap must be used. You will have stitches anywhere from 5 to 14 days depending upon the surgical site.

You will need to return to the office within the time frame recommended for suture removal. With any of the above options, your surgical site will most likely require daily care at home; you will be given detailed instructions following your surgery.

David R. Byrd, M.D., will recommend which of these options will be best for your individual case.

What happens if the wound can be closed immediately with sutures?

If we close the wound with sutures, you will be given specific instructions how to care for this area. An antibiotic may be prescribed to prevent infection. Restrictions include no bending, heavy lifting, cessation of exercise and any strenuous activity until the sutures are removed.

If the wound is allowed to heal by itself, what is the procedure?

If the wound is allowed to heal by itself (or “granulate in”) the dressing must be changed every day until the wound heals completely. All wounds normally drain, and dressings are changed daily to rid the wound of such drainage so that it does not accumulate into a crust – thus your wound heals faster. The nurses will instruct you on how to change the dressing.

How long will the wound take to heal?

If the wound is allowed to heal by itself (a process called “granulating in”), it usually heals in four to eight weeks. When healing is well advanced, you will be permitted to stop the daily dressing changes.

What happens after the wound is healed?

You may experience a sensation of tightness (or drawing) as the wound heals, but this is normal. After several months, you’ll feel this less and less.

Frequently, tumors involve nerves, and it may take up to a year, or even two, before feeling returns to normal, or near normal. Sometimes the area stays numb permanently. Only time will tell.

The new skin that grows over the wound contains many more blood vessels than the skin that was removed. This results in a red scar, and the area may be sensitive to temperature changes (such as cold air). This sensitivity improves with time, and the redness gradually fades, but if you’re having a lot of discomfort, try to avoid extremes of temperature.

Patients frequently experience itching after their wounds have healed because the new skin that covers the wound does not contain as many oil glands as previously existed. Plain Vaseline will help relieve the itching.

How often must I return to follow-up once the wound is healed?

Our practice is to have patients return for a 6 week follow up visit to evaluate the continuing healing process as well as to take post operative photos. Patients will be seen as often as necessary if any wound healing problems exist.

We then recommend you have a yearly skin exam, with your referring Dermatologist, giving special attention to any previously treated skin cancer sites.

My skin cancer has been treated several times. Will I ever be cured?

A frequent reason why you have been sent to us for MOHS surgery is that other forms of treatment have failed, or have a high chance of failure because of the cell type of the tumor. This does not mean that you are cancer prone or that you are a hopeless case. It merely means that the methods used to treat you in the past were not effective enough to destroy all of your skin cancer cells. Because MOHS surgery uses complete systematic microscopic control to search out the roots of the cancer, it has a much higher rate of cure than other methods even when skin cancer has persisted in spite of several other treatments.

Later on, must I avoid the sun?

No, not entirely. We do not think that the sunshine will be harmful to you as long as you provide yourself with adequate protection, avoid burning, and use discretion.

As mentioned earlier, sunlight is probably the main cause of skin cancer, and patients who have developed skin cancer often will develop more at a later time. Therefore, in the future, when you go into the sun, we recommend that you liberally apply a sunscreen to all exposed area, including the tops of the ears, and the bald scalp in men.

It is best to apply the sunscreen about 30 minutes before going outdoors. Be sure to apply it liberally after swimming or exercising since most sunscreens wash off with water or perspiration. Our office recommends UVA/UVB Broad Spectrum Sunscreen SPF of 15 or greater. These will prevent burning and permit you to tan gradually.

In addition to a sunscreen, you may wish to wear a broad brimmed hat and utilize clothing to further protect yourself from the sun.

Remember, it may not be necessary for you to restrict your outdoor activities or to change your lifestyle if you follow this advice.