How Bob Beat Melanoma: The Benefits of Mohs Micrographic Surgery

Mohs micrographic surgery is named after Dr. Frederic E. Mohs. As a medical student in 1933, he researched cancer with his mentor, Dr. Michael Guyer, who taught him how to prepare tissue for microscopic slides. Dr. Mohs used these techniques to map and remove cancer around nerves, blood vessels, muscle, and bone by shaving off thin layers of tissue for examination.

When Dr. Mohs first presented his procedure at a conference of plastic surgeons he was met with widespread dismay and criticism. However, his persistence laid the foundation for what is now known as Mohs surgery.

Mohs surgery has developed substantially since 1933, and it is used to successfully remove certain skin cancers.

Benefits of Mohs Surgery

During standard excision of a skin cancer, the tumor and margin — an edge of normal, healthy tissue around the cancer — are removed and sent for testing. If cancer cells are found in the margin, further surgery or cancer treatment is required. This process can take days to weeks.

Mohs surgery is different. During Mohs surgery, the visible portion of the skin cancer and a thin layer of surrounding tissue are removed. The tissue is immediately processed and examined under the microscope by the Mohs surgeon. If cancer cells are detected, additional layers from the same area are removed and analyzed. The cycle continues until no more cancer cells are identified. The wound is then repaired. The Mohs surgery technique has a 97-99% success rate and leaves the least amount of scarring possible.

A Lifetime of Sun Exposure

Bob Schuman loves the outdoors. For as long as he can remember, as soon as the temperature was 50 degrees Fahrenheit or above, he would remove his shirt and head outdoors. Bob worked in the oilfields for 44 years, spending long days in the Oklahoma sun, and hours on the golf course in his free time.

After years of sun exposure Bob had a lot of skin damage, so he was sure to have regular skin checks with his dermatologist. In June 2023, Bob’s dermatologist identified a melanoma on his right cheek. Melanoma is the most aggressive form of skin cancer, but detected early before it spreads, the survival rate is 99%.

Melanocytes are cells that make melanin, the pigment that gives the skin its color. Melanoma starts when melanocytes undergo DNA changes. Melanoma is most common in sun-exposed areas but can occur in non-sun-exposed areas, including the palms, soles, genital area, and nailbeds. Although melanoma accounts for only 1% of skin cancers, it causes most skin cancer deaths.

Bob’s dermatologist referred him to OU Health dermatologist Dr. Lindsey Collins, M.D., associate professor in the Department of Dermatology at the University of Oklahoma College of Medicine.

Removing the Melanoma

On June 26, 2023, Dr. Collins performed Mohs surgery to remove the melanoma from Bob’s cheek.

Mohs surgery is performed while the patient is awake. The area to be treated is anesthetized with local anesthetic. A scalpel is used to remove the visible cancer and a small margin of normal surrounding tissue. This tissue is then processed in the lab and examined under the microscope by the Mohs surgeon. A special stain called Mart-1 is utilized to visualize the melanoma cells. This same process is repeated until there are no more cancer cells identified. The removal of the skin cancer, confirmation of clear margins under the microscope, and repair of the wound is all done on the same day.

“I was nervous about being awake through the surgery,” Bob admitted, “but Dr. Collins is a tremendous surgeon. She was so patient and comforting. She gently reassured me and talked to me all through the procedure — her surgical and communication skills are top shelf.”

Bob’s melanoma was large, and after the melanoma was removed with clear margins, he had a large defect in his cheek that had to be repaired. Dr. Collins repaired the wound with sutures, bandaged it, and Bob was able to go home.

“Mr. Schuman was a great candidate for Mohs surgery with Mart-1 staining to treat the melanoma on his cheek,” said Dr. Collins. “The lesion was large, ill-defined, and in a very cosmetically sensitive area on his face. I was able to remove the melanoma with Mohs surgery and preserve the normal surrounding tissue, which resulted in a smaller scar for Mr. Schuman.”

Mohs surgery is also associated with a higher success rate because of the way the tissue is processed compared to conventional excision, so Bob has a very low chance of the melanoma recurring in the future.

When is Mohs Surgery Recommended?

The most common skin cancers treated with Mohs surgery are squamous cell carcinomas (SCC) and basal cell carcinomas (BCC), but it is also used to treat many other types of skin cancers including superficial melanomas, sebaceous carcinomas, dermatofibrosarcoma protuberans, mucinous carcinomas, extramammary Paget’s disease, atypical fibroxanthomas, and more. Mohs surgery is recommended for BCCs and SCCs that are considered high risk or located in cosmetically sensitive areas where tissue sparing is needed. Mohs surgery is especially appropriate for skin cancers that:

• Are large or fast growing
• Have recurred after previous treatment or are likely to recur
• Have ill-defined borders
• Develop in areas where preserving cosmetic appearance and function is important including lips, ears, nose, scalp, genitals, feet, or hands
• Are located in scar tissue
Bob was amazed at how well the wound on his face from the Mohs surgery looked.

“I had no idea what Dr. Collins could do,” said Bob. “The difference between the first day of surgery on my cheek, and 90 days later was amazing. The wound was kind of gruesome — a hole bigger than a silver dollar — but I am so surprised in how skilled she is and how well she made me look.”

Skin Cancer

Skin cancer is the most common cancer in the United States, with over 5 million people diagnosed each year. More than two people in the United States die from skin cancer every hour.

The American Cancer Society reports that the risk of melanoma increases with age. The average age of diagnosis is 66, but melanoma is not uncommon among people under the age of 30. It is one of the most common cancers in young adults, especially young women.

The primary risk factor for skin cancers is excessive exposure to sunlight. Additionally, hereditary factors play a role, particularly in certain ethnic groups with fair complexions and reduced tanning abilities. Fair-skinned individuals are more prone to skin cancers than those with darker skin. Exposure to radiation, trauma, and specific chemicals may also contribute to skin cancer development.

Early detection of skin cancer is key, and this is only possible when you perform monthly head to toe examinations of your skin and have any changes checked out by your dermatologist.

OU Health Dermatology provides excellent dermatological care for patients of all ages and backgrounds.

“We have experts in every area of dermatology including cutaneous oncology/high risk skin cancers, cosmetic dermatology, complex medical dermatology, dermatopathology, and skin of color,” said Dr. Collins. “We have the most up-to-date treatments available for our patients. OU Health is the only practice in the area offering Mohs with Mart-1 staining to treat melanoma which provides patients with the best possible outcomes. In addition, being a part of a large academic center provides opportunities for collaboration with specialists in other medical fields which is often times necessary in complex cases.”

OU Health Dermatology

Learn more about the OU Health dermatology services and treatment including Mohs surgery. Request an appointment, get a second opinion, or find out more about the skin cancer team at OU Health by calling (405) 271-6110.