Patients

Mohs Surgery

1. Surgical Center

Alpharetta Mohs Surgical Center, LLC

State licensed Ambulatory Surgical Center conveniently located adjacent to our Alpharetta office.

Alpharetta Mohs Surgical Center is owned and operated by Dr. Katarina Nalovic (formerly Dr. Katarina Chiller). When having your surgery performed in our Alpharetta location, Dr. Nalovic will perform your reconstruction (wound closure) in our Surgical Center. In this case, your nurse will simply move you from the office procedure room down our common hallway to the Surgery Center, so as to facilitate the transition. Having your surgery performed in the Ambulatory Surgery Center rather than in a regular office setting in of benefit to you, as the established standards in quality of care required to be a licensed Surgery Center are very strict and rigorous. Being licensed by the state as a Surgical Center is a testimony to our commitment to excellence.

Please note that when you receive your statement from procedure performed, there will be an invoice for the doctor’s fee, and invoice for the surgery center, and you may receive a separate bill from the pathology laboratory if biopsies are obtained.

2. Procedure

The Procedure

The Mohs surgical process involves a repeated series of surgical excisions followed by microscopic examination of the tissue to assess if any tumor cells remain. Some tumors that appear small on clinical exam may have extensive invasion underneath normal appearing skin, resulting in a larger surgical defect than would be expected. It is therefore impossible to predict a final size until all surgery is complete. As Mohs surgery is used to treat complex skin cancers, approximately half of all treated tumors require 2 or more stages for complete excision.

Steps in detail:

  1. Anesthesia

The tumor site is locally infused with anesthesia to completely numb the tissue. General anesthesia is not required for Mohs micrographic surgery.

  1. Stage I – Removal of visible tumor.

Once the skin has been completely numbed, the tumor is gently scraped with a curette, a semi-sharp, scoop-shaped instrument. This helps define the clinical margin between tumor cells and healthy tissue. The first thin, saucer shaped “layer” of tissue is then surgically removed by the Mohs surgeon. An electric needle may be used to stop the bleeding.

  1. Mapping the tumor

Once a “layer” of tissue has been removed, a “map” or drawing of the tissue and its orientation to local landmarks (e.g. nose, cheek, etc) is made to serve as a guide to the precise location of the tumor. The tissue is labeled and color-coded to correlate with its position on the map. The tissue sections are processed and then examined by the surgeon to thoroughly evaluate for evidence of remaining cancer cells. It takes approximately 60 minutes to process, stain and examine a tissue section. During this processing period, your wound will be bandaged and you may leave the operative suite.

  1. Additional stages – Ensuring all cancer cells are removed

If any section of the tissue demonstrates cancer cells at the margin, the surgeon returns to that specific area of the tumor, as indicated by the map, and removes another thin layer of tissue only from the precise area where cancer cells were detected. The newly excised tissue is again mapped, color-coded, processed and examined for additional cancer cells. If microscopic analysis still shows evidence of disease, the process continues layer-by layer until the cancer is completely removed. This selective removal of tumor allows for preservation of much of the surrounding normal tissue. Because this systematic microscopic search reveals the roots of the skin cancer, Mohs surgery offers the highest chance for complete removal of the cancer while sparing the normal tissue. Cure rates typically exceed 99% for new cancers, and 95% for recurrent cancers.

  1. Reconstruction

Fellowship-trained Mohs surgeons are experts in the reconstruction of skin defects. Reconstruction is individualized to preserve normal function and maximize aesthetic outcome. The best method of repairing the wound following surgery is determined only after the cancer is completely removed, as the final defect cannot be predicted prior to surgery. Stitches may be used to close the wound side-to-side, or a skin graft or a flap may be designed. Sometimes, a wound may be allowed to heal naturally.

3. FAQ 

FAQS

Frequently Asked Questions about Mohs Micrographic Surgery

  1. Will it hurt?

When we start the procedure, you will be given local anesthesia with a very small needle. Although everyone’s tolerance for pain is different, patients who undergo Mohs surgery find the procedure remarkably painless. We pride ourselves on being particularly gentle. You will be advised on the day of your procedure what can be taken for any discomfort you may experience.

  1. Will I have stitches/sutures? Will I have to come back and have the stitches removed?

You can expect to have stitches under a pressure bandage when you leave us. We typically use two layers of sutures, both of which dissolve. This means that you do not need to come back for your stitches to be removed, but you may have a follow up appointment with the doctor to make sure you are healing well. In some cases, we cannot use dissolvable sutures and you will have to come back one to two weeks after the procedure to have them removed.

  1. Will there be a scar?

Yes. It is impossible to undergo surgery without having a scar. Nevertheless, it is our commitment that you will be completely satisfied with the cosmetic outcome. This means that, in some instances, it may take extra post-operative corrective procedures to attain the desired goal. We are committed to that process.

  1. What will the scar look like?

Everybody heals at a different rate and the scar will look different over time. Initially, it will be red and bumpy, but eventually, the scar will be a barely visible “hair-thin” white line. We typically camouflage the scar in the lines of facial expression or in your natural skin folds.

  1. How many stitches/sutures will I have?

The number of stitches that you need is determined by the type of closure that Dr. Nalovic performs, the location on your body, and the size of the suture material.  Certain areas are under more tension and require more stitches to ensure the best cosmetic outcome, while other areas have less tension and therefore require fewer stitches.  We use the smallest stitches possible to improve cosmetic results and shorten the time it takes to heal; that means that the number of stitches may be higher than if we used larger thread.

  1. Will I need plastic surgery?

Dr. Nalovic performs the reconstructive surgery on site. Once your cancer has been successfully removed, Dr. Nalovic’s expertise lies in the reconstructive component of the surgery. If the cancer involves the eyelid margin, or if the reconstruction requires you to be put to sleep, Dr. Nalovic works closely with other specialists with whom we will coordinate your care.

  1. Can you do multiple surgeries at the same time?

We do not perform multiple surgeries on the same day. In general, the chances of getting an infection increase when multiple surgeries are done at the same time.

  1. How long will the Mohs surgery take?

It is all dependent on the size and site of your cancer. It is impossible to determine how long you will be with us until we have seen you. Even then, the full involvement cannot be determined until Dr. Nalovic is able to examine your tissue under the microscope. Because of these uncertainties, we ask you to plan to be with us for at least 3 hours, although it may take less time.

  1. Will I be put to sleep?

No. All of our surgeries are done under local anesthesia, which is one reason why our procedures are so safe.

  1. Can someone be in the surgery room with me?

Although we want you to feel as secure as possible while undergoing surgery, we reserve the right to determine who can be in the surgical suite based on our need for space and/or the complexity of the case.

  1. Will my insurance cover this procedure?

This is a medically necessary procedure. As a courtesy to you, we will contact your insurance company 48 hours prior to your surgery to determine your most updated benefits for your specific insurance plan. You will be updated at that time with the results of your insurance verification.

  1. Can I drive home?

Unless you have had surgery near the eye or on your hands, it is reasonable to expect that you can safely drive home.  Of course, it is always comforting to have someone give you a ride.

  1. Do I need to stop my medications?

In general, we do not recommend that you stop any medications that were prescribed by a doctor without checking with that doctor. Self-prescribed over the counter medications containing aspirin, ibuprofen, or vitamins should be discontinued if possible.

  1. Can I eat before the surgery?

We recommend that you have a light meal before your surgery. You may be with us for several hours. And, although, we can provide you with light snacks and water; we want you to be as comfortable as possible. You may even want to bring a light snack with you, which you may eat in the waiting room.

  1. Can I go back to work after the procedure?

We recommend that you go home and take it easy. Although the surgery takes place in an ambulatory setting with the use of local anesthesia, we have found that patients often feel “drained” after the procedure. Furthermore, any activity that puts strain on your surgical site or causes your blood pressure to elevate is contraindicated and could compromise the way you heal.

  1. When can I exercise?

The resting period that we recommend after your surgery depends on where your surgery site is located. Typically, we recommend that you do not exert yourself for one week if your surgery site is on your head or neck area. This restriction is increased to two weeks when your surgery site is on the trunk and extremities. Dr. Nalovic may recommend even longer restrictions for certain types of exercise. Make sure you ask us about the specific exercise you intend on doing.

  1. Do I need to have the doctor look at the site before I have surgery?

Yes. Dr. Nalovic will examine the site and determine whether Mohs surgery is the right treatment for you before you undergo surgery. Because some of our patients are quite elderly or live far away, we often schedule your consultation visit on the same day as the procedure.

  1. Will I have a follow-up appointment with the physician?

Your follow-up status will be determined by the Dr. Nalovic at the time your procedure is complete. Depending on the complexity of your case, you will either be scheduled for an in-office post-operative follow-up appointment, or you will be given a follow-up phone call by our office approximately 8-weeks after surgery to evaluate your progress. Of course, you may call our office at any time you have any questions or concerns and we will see you that same day. This is what we call our “Open Door Policy”- Please do call us first as we want to make sure we are there to see you.

  1. If I only have one stage of Mohs, was there really cancer there?

Yes.  The pathologist who looked at your biopsy saw cancer cells that were not completely removed by the biopsy which is why your dermatologist recommended the Mohs procedure to ensure complete removal of the remaining cancer cells.  During the Mohs procedure, Dr. Nalovic examines the skin/tissue under a microscope in order to see if the borders or outside edges of the skin that she removed are cancer-free (we call that “clear margins”).  If we see that the edges are cancer-free after the first stage, we know that Dr. Nalovic was able to remove all of the remaining cancer cells in the first try and there is no need to take any more skin from the area.

  1. What causes skin cancer?

People have skin cancer for multiple reasons. The two main reasons are sun exposure and genetics. Damaging sun exposure likely took place before you were 18 years old. Although it is very important that you protect yourself now from the sun so that you do not continue to get skin cancers, your current skin cancer is most likely due to excessive sun exposure 20 years or so back. Also, your genetic background determines how likely you are to be affected by sun damage. If you have light colored eyes, blond or red hair, and fair skin, you are more likely to have skin cancer. If you or any of your family members have had skin cancer, you are also at higher risks of developing skin cancer. For more information, please visit www.aad.org or www.skincancerfoundation.org.

  1. What if I did not have this treated?

If you have been diagnosed with a skin cancer, it is important that you understand what would happen if this tumor was left untreated. There are three types of skin cancers that we deal with most commonly: Basal Cell Carcinoma, Squamous Cell Carcinoma and Melanoma. An untreated Basal Cell Carcinoma is a cancer that would continue to grow at a relatively slow rate. Even if it seems to you that the biopsy took it all away, it has little extensions under the skin that can continue to grow. Eventually, it could become larger, bleed and be painful and/or disfiguring. In rare cases, it could grow down a nerve and lead to complications including death. Basal Cell Carcinomas do not spread to other parts of the body (metastasize). However, unlike a Basal Cell Carcinoma, an untreated Squamous Cell Carcinoma can metastasize. The same holds true for a Melanoma; and it can do so quite rapidly.

  1. Can I die from this?

Squamous Cell Carcinomas and Melanomas can spread to other parts of the body and lead to death under certain circumstances when the area is not treated in a timely manner. It is very rare to die from a Basal Cell Carcinoma. Again, the concern with Basal Cell Carcinoma is that it can be disfiguring and lead to loss of function of nearby anatomical structures.

  1. Can I postpone the surgery*?

We do not recommend doing so. Your doctor has sent you here for us to remove your cancer and it should be addressed as soon as possible. It is important that you keep your appointment and not reschedule, so as not to delay your treatment.. Delaying surgery could allow your cancer to grow larger, making the reconstruction and your recovery more complicated. In the case of Squamous Cell Carcinomas and Melanoma, it may even lead to the spreading of the cancer.

*Please note: We require 48-hours notice when cancelling/rescheduling a surgery. Surgeries cancelled with less than 48-hours notice may incur a $150 cancellation fee.

  1. Anything else?

We recommend a shower the evening or morning before surgery and do not apply make-up, creams, shaving lotion, etc. to the affected area.  We also recommend freshly laundered loose fitting clothes to help reduce the chance of you getting an infection. Wear a shirt or blouse that buttons up the front.  Please be aware that clothing may get stained during your procedure. You may also want to bring a jacket or sweater, as our office tends to be a little cool.  You will be here for several hours on the day of surgery, so bring a good book or something to occupy yourself.