Beneath the Surface: A small red spot on your skin may be just the tip of the iceberg. A Mohs surgeon may discover an extension of the cancer not visible from the surface. Photo: Ales Utovko/ISTOCK/Getty Images Plus
Q: I am a little nervous about Mohs surgery for a skin cancer on my face. Will I have a big, ugly scar?
Hooman Khorasani, MD: I spend about 50 percent of my time doing Mohs surgery, and I am careful to reassure patients as well as manage their expectations. Most cases are basal cell carcinomas (BCC) and squamous cell carcinomas (SCC), and when these common types of skin cancer are detected early, they’re almost always curable. We’re definitely going to take care of it and get rid of the cancer. That’s the most important thing. But I know that many patients also care about a good cosmetic outcome.
It’s important to understand, though, that the wound that will be created during surgery on a BCC or SCC will be bigger than you might have guessed. While your skin cancer may have looked like a small red spot when diagnosed, that can be just the tip of the iceberg. There may be extensions, or “roots,” of the cancer that are not visible from the surface that will be discovered during Mohs surgery, requiring the removal of more tissue. But we remove the least amount of healthy tissue necessary to get the job done.
Once no more cancer cells can be detected on the margins of the tissue, my focus shifts to closing or reconstructing the wound. Often it is possible to hide a scar in the natural lines of the face. To make a scar that lies flat and looks good, surgeons shape the wound so it looks more like a football (an “ellipse”) than a circle, which lengthens the scar. The ratio between the diameter of the circle to the length of the ellipse is 1 to 3. That means the length of the scar will be about six times the diameter of the original lesion. Public education about this is crucial: A recent study in JAMA Dermatology found that when patients scheduled for Mohs surgery on their face were asked about their expectations before their surgery, more than 80 percent underestimated the length of their scar by about half.
To help your scar look its best, follow your doctor’s instructions for post-op care. For about two weeks after surgery, the wound has only a fraction of its original strength, so limit activity that can stretch the scar and affect the way it will heal. Silicone has been shown to reduce the thickness of some scars, so after your stitches have been removed, you can apply an over-the-counter silicone sheet or gel as directed. New scars tend to darken and discolor when exposed to ultraviolet (UV) light, so be diligent about protecting your scar from the sun — and the rest of your skin while you’re at it!
If you’re not happy with the appearance of a scar, talk to your doctor about the treatment options to improve it. We now know that early scar intervention around six to eight weeks works much better than traditional intervention after six months. — Interview by Julie Bain
About the Expert:
Hooman Khorasani, MD, who has a private practice in New York City, is quadruple board certified in dermatology, Mohs surgery, cosmetic surgery and facial cosmetic surgery and has done extensive research on minimal scar wound repair.
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