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Mohs Surgery

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Vincent C. Hung, M.D., F.A.C.S.

Dr. Vincent Hung is the only board certified plastic surgeon in Southern California who performs Mohs surgery. He is also the only physician in the country who is board certified in internal medicine, dermatology, plastic surgery, and has trained in a one year Mohs surgery fellowship. Dr. Hung has been in private practice since 1995, and has performed Mohs surgery, post Mohs reconstruction, and plastic surgery. This unique training, background, and experience allows you, the patient, to benefit from both state of art Mohs surgery, and plastic reconstructive surgery provided by Dr. Hung.

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What is MOHS Surgery?

Mohs surgery is a specialized surgical method to remove skin tumors. In an outpatient office procedure the surgeon initially removes the visible tumor. Next, a rim of tissue is taken completely around the site. This thin specimen is then marked with dyes for orientation purposes and a map is made of the specimen. The tissue is then prepared akin to an orange peel map of the world so that 100% of the perimeter around the tumor can be evaluated. The surgeon then personally analyzes the prepared tissue. Any residual tumor is identified and precisely mapped. This allows the surgeon to remove more tissue at the specific site of residual tumor. The procedure is repeated until the tumor is completely removed.

What are the advantages of MOHS Surgery?

In conventional surgery only a small percentage of the margins of the removed tissue are actually examined. In contrast Mohs surgery allows for 100% of the perimeter of the specimen to be evaluated. Mohs surgery has the highest cure rates for the treatment of most skin cancers. In addition, because thin layers of tissue are removed the least amount of tissue can be removed thereby maximizing the potential for the best cosmetic result.

What should you do prior to surgery?

You have the option of filling out your medical information now via the Nextech link prior to your appointment; or to download and fill out the information sheets available at the website and bring to your first appointment; or we can mail necessary paperwork at your request so that it can be completed and brought into your first appointment.

Today there are a myriad of blood thinning agents prescribed by doctors such as Coumadin, aspirin, Plavix, eliquis, xarelto, and Pradaxa. Ideally prescribed blood thinner medications would be held prior to surgery to help minimize bleeding and bruising. These medications CANNOT be stopped without the approval of your prescribing physician. Also the length of time that these medications are held and then resumed must be approved by your physician.

We will contact your physician after your consultation with us to obtain this information. We will contact you within one week of your surgery as to when to hold your blood thinner medication. If you do not hear from us within one week of your surgery date, you should contact us.

Other medications can have incidental blood thinning properties primarily NSAIDS (Non-steroidal anti-inflammatories) such as Naproxen, Indocin, ibuprofen, Celebrex, and Aleve. We will discuss how to manage these non-prescription medications with blood thinning effects, at the time of your consultation.

Generally prophylactic aspirin and NSAIDS should be held 10 days prior to surgery and resumed 3 days afterward. In addition, you will be given a list of supplements that have blood thinning properties that should also be held a week prior to surgery. These general guidelines will be further discussed during the day of your initial consultation.

You should not smoke for 7 days prior to and after surgery. You should not have any alcohol 3 days prior to or after surgery. You should continue all other medications. You especially should remember to take your antihypertensive and diabetic medications the day of your appointment. You should eat a regular meal prior to surgery and dress casually.

We are a fragrance free facility, and ask that all perfumes and perfumed lotions be avoided when coming for all appointments by both the patient and any loved ones/caretakers who accompany the patient.

What should you expect the day of surgery?

You will be notified a day or two before your actual surgery day with the actual time of your surgery appointment. You do not need to come in earlier than that actual time given. You should not have any other plans or appointments for the rest of the day. You should plan on spending the rest of the day with us. If your appointment time is in the afternoon, you should anticipate being with us until the evening.

Most reconstructive procedures can be performed during the same day. Particularly complex or lengthy procedures may be scheduled for a separate day.

We may recommend that someone drive you to and from the office or accompany you on your day of surgery. This recommendation will be based on multiple factors such as size of lesion, location of lesion, and contemplated reconstruction. We will discuss specific recommendations for you during the day of your consultation. You may want to bring a book, tablet, or laptop that day. We do have Wi-Fi service and password will be provided. You also may wish to bring a snack or lunch depending on your appointment time.

Will I have much discomfort?

Local anesthetic will be administered at the time of surgery in which there is generally minimal or no discomfort. After surgery you may have some discomfort. You can take Tylenol or receive a prescription of Tylenol with codeine. Depending on the location of surgery, you may have swelling and bruising after surgery. You should not take aspirin or nonsteroidal anti-inflammatory for at least 3 days after surgery.

When will I need to return?

Usual initial follow up after surgery is in 5-7 days for suture removal. Further checks are generally spaced every 1-2 weeks until the wound is closed. Periodic checkups will be scheduled until the wound is well healed. Once your condition is stabilized, you will return to your referring doctor for further routine follow ups.

 


“Don’t Pick the Dandelions…”

Wound healing is a very complex process. Most people think that once the stitches have been removed, that’s all there is to wound healing. To the contrary, the majority of wound healing begins and is completed after the stitches are removed. When one looks at a scar, because of the thickness and textural changes, it is easy to assume that a scar has more strength than the original skin. Just the opposite, a mature scar at one year has only about 75% of the strength of uninjured tissue.

When the stitches are removed in a period of generally five to seven days, for facial surgery, and one to two weeks for surgery elsewhere, the incision is held closed merely by a thin layer of skin or epithelial cells. During this time the wound has only approximately 10% of its normal wound strength. Post-surgical incisions, at this point in time, are most vulnerable for re-opening. During this period of time you must be the most careful to avoid excessive trauma or stress to the wound. This period of special care will last anywhere from two to four weeks depending on the body part, and the specifics of your surgery will be discussed with you.

I tell patients that their wounds will look initially well healed when the stitches come out. Then for the next period of two weeks to two months, the wound will be undergoing new collagen formation (scar formation) internally and externally. During this time, the incision can become quite red and lumpy. If nothing is done to treat this condition, the redness and lumpiness will spontaneously abate. However, it can take several months to do so. You will be given specific instructions on what kind of wound care you should perform during this period of time. Specifically, it is very important for you to avoid sun exposure to the wound because this will prolong redness. Therefore, the area should be covered with sunscreen, tape or make-up once the immediate post-operative wound healing period is complete, and no daily wound dressing or care is needed. In some cases you will be advised to massage the area and in other cases a silastic gel will be used to give compression to the area to help reduce the amount of lumpiness. Finally, in some other cases, other procedures, such as a scar revision with laser resurfacing or Kenalog (steroid) injections, may be advised.

Specific Post-Operative Instructions:

  1. Avoid all aspirin or non-steroid anti-inflammatory drugs for the first three days post operatively, unless otherwise instructed. A list of medications to avoid will be included in your pre-operative instructions.
  2. No alcohol for three days post-operatively because alcohol can cause vasodilatation and bleeding.
  3. No excessive or strenuous exercise for at least the first three weeks post-operatively. This will differ for different areas of the body where surgery is done. For example, if you have had facial surgery, you should avoid bending down as much as possible (tying your shoes or picking up objects).
  4. For all patients, regardless of where surgery was performed, lying or sleeping on the side on which surgery was done should be avoided.
  5. For patients who have had surgery around the cheeks or lips, it is very important that activity be minimized for a period of two to three weeks until otherwise instructed. Therefore, if surgery has been performed around the mouth, one should avoid excessive animation: laughing, smiling, and eating any hard foods (steaks, apples…). Soft or liquid food is preferred.
  6. For surgery done on the lower extremities, the leg needs to be elevated as much as possible. Activity and weight bearing involving the feet should be minimized. If you have pain or tenderness, this is an indication that you are doing too much. Activities such as running, jogging, or walking up and down stairs are to be avoided and should be discussed with our office before being done.

Healing Rate

As you can see after reading the above information, taking care of yourself after surgery and after the stitches have come out is very important. One of our patients who thought she was “completely healed” the day her stitches came out couldn’t resist picking all the annoying dandelions in her garden in the rain. She found out the hard way she had a long way to go towards complete wound healing. Thus comes the title of this information, “Don’t Pick the Dandelions.”