Microscopically controlled surgery (Mohs) Patient Information

• Bleeding: you may get some oozing from the wound after the operation. This is usually not serious but may lead to bruising. If this bleeding continues, it can usually be stopped by holding firm pressure on the wound constantly for 20 minutes. 
• Scarring: every attempt is made to repair the wound in a way that will allow the scars to be hidden as much as possible. We will discuss repair options on the day. 
• Incomplete removal and further treatment: we double check some results afterwards and very rarely find a tumour has been missed on the day. This can mean we recommend further treatment, but not always. 
• Recurrence: the tumour rarely regrows years later.
• Allergic reactions: this is extremely rare but you can get a reaction to rubber gloves, antiseptic solution, local anaesthetics, antibiotics and the dressing. Make sure to tell the doctor if you are allergic to any of these. 
• Delayed repair: rarely if your tumour is complex, you may need to return a few days later for further surgery and repair. Occasionally, the wounds are large or complex and you may need another specialist surgeon, which we will discuss and arrange with you.

Things to be aware of: 

• You will need to arrange time off from work or your usual responsibilities for at least 1 week after the surgery. The amount of time will depend on the complexity of surgery and the type of activities you normally do. You do not want to go on holiday within at least 2 weeks of surgery, which allows sufficient time for the wound to settle down and to have most problems dealt with before you go. Please discuss this with the doctor.
• You may eat and drink normally before and after your operation, unless told otherwise.
• If on Warfarin, please get a blood test (INR) five working days before surgery and find out the result. Please bring this result with you. The INR should be steady and between 2 to 2.5 ideally. If not please contact us straight away and ask your GP to alter your dose. If not we may have to cancel your surgery when you arrive.
• We do not usually ask you to stop aspirin or other ‘blood thinning’ tablets unless you are taking more than one together. This should be discussed with you in clinic. These medicines include aspirin, dipyridamole (Persantin or Asasantin Retard), clopidogrel (Plavix), warfarin, dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto), edoxaban (Lixiana), and heparin. Usually, the reason for taking the medicine is more important than the minimal risk of a bad experience from some bleeding or bruising after surgery.
• Take all other regular medications as normal.
• Before you attend for surgery, please remove all make-up and jewellery from your face (i.e. earrings), not just from the area being treated.
• If your surgery is in a hair-bearing area, we may clip the hairs nearby to improve access and ease of dressings. If you are shaving, please do so the night before surgery. There is some evidence that shaving just before surgery can increase the chances of wound infection.
• Please tell the doctor well before your operation if you have any implanted devices - for example a pacemaker, defibrillator, deep brain stimulator etc. You may need a device check before the procedure if your usual check is overdue. If so, we will arrange that and let you know.
• Smoking harms the healing process. You can improve your chances of good healing and a better scar by stopping smoking at least a few days before surgery, until at least a few days afterwards. This can be a good opportunity to kick start stopping altogether if you wish, which will help your general health too.
  For Stop Smoking advice phone: 
  0300 123 1044 
  or visit 
  Quit smoking - Better Health - NHS (www.nhs.uk)

Please come to the Brunel building at Southmead Hospital. Report to the waiting area at Gate 24b. You will need to allow enough time to reach Gate 24b before your appointment. When you have arrived, a nurse will escort you to the theatre area, where you will be given a hospital gown to wear.

If you are late your operation may need to be cancelled. At times parking can be difficult so allow plenty of time. You can travel to the hospital by whatever means you wish, but you will not be fit to drive yourself home or use public transport after the operation.

The lesion may be photographed before and during the procedure with your consent. Local anaesthetic is injected to numb the area. You will be fully awake throughout the procedure. You may need repeated injections throughout the day to keep the area numbed. 

Occasionally if your wound is large or complex, another type of specialist surgeon may come to reconstruct your wound or might do this at your local hospital if you live far from Bristol. Sometimes you may need to go to the main operating theatres upstairs in the hospital for part of your operation or reconstruction. This will usually have been arranged in advance, and sometimes might involve a general anaesthetic.

Stitches

If you have stitches in your wound, we often ask you to come back the following week for them to be removed, or you may need to arrange to have them removed at your GP surgery.

If a change of dressing is needed, then either the practice nurse at your local GP surgery or district nurse could 
usually do this for you. We can help you arrange this on the day of surgery.

Will the area be painful afterwards?

• After the local anaesthetic has worn off (approximately 2 hours), the area will often be somewhat painful and we advise you to take regular Paracetamol for the next couple of days (depending on your usual medications).
• You may experience some bruising and swelling; this should settle down within a few days, but may last longer.
• The surgeon may prescribe a course of antibiotics for you to take after the operation.

How will the wound be repaired/reconstructed?

There are several options depending on the size and position of the wound.

Healing naturally (secondary intention healing)

• What does this mean? Healing naturally usually takes longer than if closed together (about one to two weeks per cm of wound diameter). It may be a good choice for a small wound that cannot easily be closed together or if you want a simpler, quicker operation to avoid a skin graft or skin flap, and reduce your visits to hospital.
• How do I care for the wound? The wound will require a change of dressing two or three times per week until healed, but this is usually done by your GP practice or district nurse.
• What will my scar look like? In the right area healing naturally usually ends up looking very good, but this can take many weeks.

Direct closure (sewing the edges together usually in a line)

• When can this be done? Most Mohs surgery wounds are too complex to use this technique. Otherwise this usually gives the quickest healing, easiest aftercare, and best scar.

Skin graft (using a patch of skin from somewhere else)

• Where does the skin graft come from? The “donor” site is usually where the skin is loose and thin and it is easy to stitch the edges together (e.g. above your collar bone, neck, or behind your ear).
• How is the skin graft put on? The graft will usually be stitched in place. Often, a small wad of dressing material is stitched over to hold the graft firmly.
• What will my skin graft look like? Usually some bruising and crusting in the first few weeks. It can take up to 18 months for a scar to ‘mature’, usually becoming pale, soft, flat and supple. Your doctor will do their best to match the skin graft to the skin removed so that it blends in as much as possible. Sometimes it is almost unnoticeable, but other times it is more difficult to hide and the differences to the surrounding skin are more obvious.

Local flap (moving nearby skin or muscle whilst still attached)

• What will my local flap look like? The aim of using nearby skin is to provide a better match to the skin removed. Usually this is successful but the appearance varies similar to skin grafts.

Bleeding

When you go home you will have a bulky dressing covering your wound; this is essential for pressure to stop any bleeding. It is important to leave this on. If you experience bleeding from the wound, apply direct firm pressure to the wound for 20 minutes. This should stop the bleeding. If this does not help contact us on the numbers below, or your GP.

Infection

The usual signs of infection are pain, swelling, redness, increased temperature of the skin near the wound (or a fever), pus from the wound. Pain, swelling and redness are common in the first three days after surgery but should be improving. If not, the wound may be infected, and you may need antibiotics. If you see these signs seek medical advice from us or your GP.

• It is advisable to avoid alcohol for 48 hours after surgery to reduce the risk of bleeding.
• If you are elderly or frail, we recommend having a relative or friend with you overnight after the surgery or at least contactable nearby.
• Avoid bending over, straining, or exerting yourself, and sleep more upright than usual (i.e. with an extra pillow) for a few days to reduce swelling.
• Once healed, care for any skin graft with daily moisturiser, and sunscreen when exposed. Grafts remain more sensitive long term.
• Leave the dressing in place and dry for the first 48 hours, then remove it carefully or soak it off, unless you have been told otherwise (e.g. for skin grafts it is left     untouched for 7 days and removed by us in hospital).
• Change a dressing if it gets wet or dirty. A wet dressing can lead to an infection. For skin grafts just change the outer dressing and do not disturb underneath, or contact us.
• Keep the wound clean. Wash it daily after dressings have been removed, but avoid the direct force of the shower on the wound.
• Apply petroleum jelly (e.g. Vaseline) from a new clean pot with a clean cotton bud several times a day.
• You may have self absorbing stitches. These usually fall out within 3 weeks. Otherwise, stitches are usually removed after 7 days, in hospital or at your GP practice. 

If you want to know more or have any questions or concerns, please contact us. 

If you have trouble with your wound in the days after surgery, the Dermatology nurses can be reached on  0117 414 8704 between about 9am - 5.30pm most weekdays, or call the secretaries on 0117 414 7621.

There is no Dermatology on-call service for wound problems out-of-hours, so there is a formal arrangement between Dermatology and Plastic Surgery to provide help instead.

• Between 5 - 8pm on Monday to Friday, and between 8am - 8pm at weekends, please call the Plastic Surgery coordinator on 0117 414 8300. 
• After 8pm, please call Southmead Hospital on 0117 950 5050 and ask to be put through to the Plastic Surgery SHO on call, quoting this leaflet.

Other options for problems out-of-hours include advice from your local out-of-hours GP service, walk-in centre, or the Emergency Department. If you must seek help show them this leaflet and please let us know what has happened as soon as possible afterwards.

If you cannot attend or no longer need your appointment, please phone 0117 414 7416 and tell us.

Appointments are precious. Enable another patient to take your place. Please give us as much notice as possible.