What is Mohs Surgery?

Mohs surgery is a precise surgical treatment used to treat skin cancer. Cancer containing skin is progressively removed in thin layers and examined under the microscope until only cancer-free tissue remains. Mohs Surgery is the preferred treatment for skin cancer in cosmetically and functionally sensitive locations, such as the face, neck, hands, and feet. It is also used frequently for aggressive or large skin cancers on other parts of the body.

The main goal of a Mohs Surgeon is to remove all traces of skin cancer while sparing normal surrounding, healthy tissue.

Michael Graves, M.D. and Stephen Houston, M.D. perform Mohs Surgery in Austin at Southwest Skin Cancer & Vein Clinic. Dr. Graves and Dr. Houston have performed thousands of Mohs surgery procedures and enjoy an excellent reputation for their expertise.  Dr. Graves joined our clinic in 2015 after completing a prestigious training program in Mohs skin cancer surgery and facial reconstruction. Dr. Graves has a passion for surgical reconstruction utilizing advanced techniques in wound repair.

How is Mohs Surgery different than other methods of removing skin cancer?

Mohs surgery is the most precise method for removing skin cancer and is the gold standard for skin cancer removal, with a cure rate of almost 99% for many lesions.

  • Most other skin cancer removal techniques either remove or destroy significant areas of normal tissue around the skin cancer.
    • Since the absolute minimum of normal skin is removed during Mohs surgery, it leaves the smallest surgical wound possible.
  • The increased size of wounds left with other skin cancer removal techniques means repair can be larger and more complicated.
    • Smaller wounds with Mohs surgery allow for less complicated surgical repairs, which makes an excellent cosmetic result more likely.
  • Other techniques of skin cancer removal can require a patient to go to a surgery suite and be put under general anesthesia, which has significant risks and complications.
    • The Mohs procedure is performed under local anesthesia, meaning substantially increased safety, decreased downtime and minimal complications.

What training did Drs. Michael Graves and Stephen Houston receive in order to practice Mohs Surgery?

Mohs surgery requires specialized training and experience in skin surgery and laboratory analysis of cancer tissue. During the Mohs surgery procedure, the surgeon performs a detailed microscopic analysis of cancerous tissue in our specialized laboratory on-site at Southwest Skin Cancer & Vein Clinic.

  • Michael Graves has received advanced fellowship training in Mohs surgery at Scripps Clinic in La Jolla, CA under the direction of Dr. Hugh Greenway, a leader in the field of dermatologic surgery who trained direct under Dr. Frederick Mohs, the inventor of Mohs surgery.
    • Additionally, Dr. Graves received extensive training in facial reconstruction working directly with top plastic surgeons, head and neck surgeons, and oculoplastic surgeons.
  • Stephen Houston has been at the forefront of skin cancer treatment in Austin, Texas as one of the first Mohs surgeons in the state of Texas and has amassed decades of experience.

What can I expect for my procedure on surgery day?

Mohs surgery follows this general order:

  • After local anesthesia is given to numb the surgical area, the cancer will be removed with a small border of normal tissue around the edges and underneath the cancer.
  • The cancer specimen is then examined microscopically by the surgeon to ensure that all the outer edges and undersurface are free of cancer cells.
  • If any cancer cells are seen at the edges of the specimen, then further small layers of skin tissue are excised and evaluated in a similar fashion.
  • Once the cancer is fully removed, the open area can be closed surgically.

Do I need anesthesia for Mohs Surgery?  

  • Mohs surgery consists of the removal of skin cancer under local anesthesia.

What can expect regarding my wound healing?

  • Graves and Dr. Houston are well versed in advanced wound healing techniques and surgical reconstruction.
  • The vast majority of Mohs surgical wounds are able to be repaired immediately, and depending on the situation, some may be allowed to heal without surgical repair.
  • In select cases, our surgeons may think it best to refer their patient to a plastic surgeon for reconstruction.
  • All of these options are discussed in detail with each patient so that a joint decision regarding wound healing can be made.

Frequently Asked Questions regarding Mohs Surgery for Skin Cancer

  • When should I arrive for my Mohs Surgery appointment?
    • Please arrive 15 minutes before your appointment time to allow for paperwork and check in to be completed.
  • How long should I expect to stay?
    • Mohs surgery is unpredictable by nature, as every patient’s skin cancer is different. Be prepared to spend a few hours, and in rare situations the entire day, in the clinic.
  • What will be happening during the Mohs Surgery and tissue evaluation process?
    • The initial removal can take 15-30 minutes to remove. Processing of the tissue can take anywhere from 45 to 90 minutes, during which you will be waiting in the lobby or break room.
    • Depending on your skin cancer, we may need to take multiple layers, each which will take anywhere from 45 to 90 minutes to process
  • What happens once all of my skin cancer is removed?
    • Once your skin cancer is cleared, the doctor will discuss surgical closure options, which could be allowing it to fill in on its own or a surgical repair, such as  a straight line closure, flap, or graft.
    • If stitches are used, you will have them removed in 7-10 days after the procedure.
    • Wounds without stitches usually will heal over a period of 4-6 weeks. This will be discussed at your appointment.
    • In special cases, dissolvable stitches can be used which do not require a follow- up appointment.
    • Occasionally, the doctor will feel it best to have a plastic surgeon, head and neck surgeon, or oculoplastic surgeon perform the closure. This will be discussed at the time of surgery.
  • What kind of closure will I need?
    • The depth and extent of skin cancer is difficult to predict, but the majority of wounds can be closed with a straight line closure.
    • In more complex areas (such as the nose, eyes, ears, & mouth) flaps* or grafts** may be needed.
    • Some wounds will heal best without any repair.
    • Every surgical wound is unique, and your doctor will discuss the benefits of each repair option in detail with you. You will have the opportunity to ask any questions you may have before the repair is performed.

*A flap involves using nearby tissue to fill in a defect while minimizing the noticeable deformity.

** A graft involves taking skin from one area and stitching it on another.

  • What limitations will I have after surgery?
    • Plan to take it easy after you go home, meaning no athletics such as golf, heavy lifting, or other vigorous activities for at least 1 week. Surgery on the lower leg can limit activities for longer.
    • Please do not schedule surgery near a vacation or time when you will not be available to return for follow up.
  • How will I take care of my wound after surgery?
    • We will send you home with detailed wound care instructions.
    • MOST patients will need to keep the wound site dry for 24 hours. After that, you will be able to apply petrolatum (Vaseline) ointment twice daily until the wound is healed.
    • Your doctor will specify if any other special wound care instructions are needed.
  • Should I eat before my surgery?
    • Yes! Eating breakfast or lunch is typically encouraged.
  • What should I wear on surgery day?
    • Dress comfortably. As our surgery rooms are kept cool, consider bringing a light-weight sweater.
  • What should I bring with me on surgery day?
    • Bring something to do while you wait, as you will be here for several hours. Many patients bring books or laptops. Wifi and magazines are available.
    • Light snacks are available in the break room. Patients are encouraged to bring their own favorite snacks as well.
  • Can I drive immediately after the surgery?
    • The majority of surgery patients are able to drive themselves home after the procedure. Your doctor will let you know if you will not be able to drive home.
    • Any patient who has taken relaxing medications such as Xanax may NOT drive home and will need a driver.
  • Can I drink alcohol before or after the Mohs surgery?
    • Alcohol thins the blood and can increase the risk of bleeding during and after the surgery.
    • We recommend no alcohol consumption for 3 days before surgery and 1 day after surgery.
  • Can I smoke before or after the surgery?
    • Smoking can significantly slow the wound healing process and can increase complications, including infections and more apparent scarring.
    • While we recognize not all patients are able to stop smoking after their surgery, we do recommend reducing tobacco intake after surgery. For instance, smoking half as often can significantly improve wound healing.
  • What medications can I take?
    • The following medications increase your risk of bleeding during your procedure and should be stopped one week before your procedure unless prescribed by your doctor for a medical condition:
      •  Ibuprofen, Vitamin E, Gingko, Garlic, Ginseng
    • Otherwise, take your usual medications before your procedure.
    • Bring a list of all the medications you take on a regular basis with you on surgery day.
    • If you require antibiotics before procedures or have been advised to take an antibiotic because of a recent joint replacement or abnormal heart valve, please let the nurses know ahead of time so they can arrange for you to have antibiotics the day of your surgery.
    • If you are taking Aspirin, Plavix, Coumadin, Eliquis, Pradaxa, or Xarelto because you have had a stroke, atrial fibrillation, heart attack, or a blood clot, you should remain on these medications for the surgery.
      • These medications are likely to increase the risk of minor bleeding during your surgery, but minor bleeding can be controlled and is less dangerous than having another stroke, heart attack, or blood clot.
    • If you are taking Aspirin for prevention, but have not yet had a stroke, heart attack, or blood clot, you can stop the aspirin 10 days before your procedure, unless you have been instructed by your primary care doctor or internist not to do so.
  • What if I have more questions?
    • Feel free to call us during business hours for further information at 512-444-7208.
    • You should feel that you have ALL of your questions and issues addressed prior to the surgery.
    • The doctor will provide an opportunity for you to ask any questions on surgery day, before the Mohs Surgery is performed, as well.