There is a difference between the basal and squamous cell carcinomas in one group and melanomas in the second group. The first group grows slowly with cells moving outward and inward. Unlike the melanoma, these cells are derived from the outer layer of skin in the embryo. Only much later, if at all, do skin cancer cells move to other distant places. They rarely cause fatality. They demand great respect, however, because of their roots and tentacles which can push between different planes of tissues like slowly growing plant roots and can spread along the outside of nerves and through and around blood vessels like a bad case of crabgrass in a yard.

The second group (melanoma) grows in fits and starts until cells break off and enter into the lymph vessels and travel beyond a point that they can be tracked with standard cutting techniques. They too can grow slowly outward and inward. They can much more easily cause internal spread to organs and lymph nodes. A few fractions of a millimeter of depth as measured from the top of the tumor to the interior bottom of it (called the Breslow level) will determine whether the patient needs to have a wider diameter surgical removal, removal of lymph nodes and/or a much more complicated tumor-seeking study by a medical, surgical and/or radiation oncologist (cancer specialist). In a biopsy showing a melanoma, the presence of internally dividing cells and/or an ulcer and/or the presence of inflammation cells and/or blood vessel tissue and/or the presence of tumor cells around nerves yields for the patient a poorer survival rate.

There are a number of ways to control and cure skin cancer of every type, much of which can be performed under local anesthesia. These ways include surgically cutting out the cancer and repairing the defect with stitches, with immediate or more frequently one or more weeks’ delayed production of pathology microscope reports. This process may result in the (un)necessary removal of healthy skin and/or the persistence of tumor cells which may or may not be detected by certain methods of tumor study under the microscope, thereby leading to an incorrect conclusion.

Sometimes skin cancers of the basal and squamous cell type are simply scraped and dried up with an electric pencil, with a presumption of full cancer removal. Other forms of cancer treatment of the basal and squamous cell type include destruction with a cold solution, acids, lasers and other destructive methods, radiation therapy, immune therapy, tumor suppressing medication, etc. Each method of course has its own benefits and downsides.

One specialized form of cancer removal for the first group, namely, basal and squamous cell carcinoma, is called Mohs Micrographic Surgery, after the inventor of this technique, Dr. Frederic Mohs. It has multiple benefits in many cases over other treatment techniques. At the same time, it is important to remember the old saying that if the only tool that a person has is a hammer, then everything looks like a nail. Physicians who are thoroughly well-trained about the techniques of cancer removal and repair are expected to possess a clear comprehension of this mindset. They will fine tune their decisions for treatment of cancer with their extensive knowledge database.

Mohs Micrographic Surgery has several advantages: reliable and more thorough techniques of tumor removal, improved preservation of surrounding normal non-cancerous tissues and frequent provision of a smaller defect in the skin. These allow for, most importantly, lower rates of regrowth of a tumor, a better quality repair, quicker healing and a better chance for preservation of the cosmetic aspects of the site, especially in the hands of well-trained reconstructive surgeons.

Dr. Kivett routinely counsels his patients as to the priorities noted above and attempts as best possible to accomplish all three of those in the very first surgical session. On occasion, some future additional work will be needed. However, one must never mistake the priorities order: first, deal with the tumor thoroughly; next, begin to heal the wound, restore the function of the area and not distort other nearby structures; and then pay attention to the cosmetic considerations.

To the best of our knowledge, there are in the U.S. two board certified plastic surgeons who are also board certified in dermatology and who have received substantial additional training in Dr. Mohs’ surgical techniques. Dr. Kivett is one and the other one is located in Pasadena, California.

Mohs surgery is especially good in cases where the cancer has come back after having been previously treated by a variety of methods and/or those cancers with a higher potential to grow back because of the presenting size or the sub-type of tumor with a greater propensity to recur. A few years ago an expert panel of doctors doing this type of work put together a Mohs decision-making algorithm taking into account a variety of factors that would influence the choice of Mohs surgery over other tumor-removing interventions.

The algorithm is a free app available online, named Mohs AUC (Appropriate Use Criteria). It takes into account the tumor name, anatomic site and size, whether or not the tumor is new or has regrown from before, whether it is shallow or aggressive by way of specific microscope findings, whether the patient is healthy or has immune system problems or genetic syndromes at high risk for skin cancer, and then it assigns a score from 1 to 9. Those scoring 7 – 9 are fully appropriate for Mohs surgery. A few in the 5 – 6 range may qualify as well, depending on circumstances. Any lower scores will indicate that it is best to have other types of treatments.

This algorithm is used only for the first group, basal cell and squamous cell carcinoma. Although there have been some efforts to apply the Mohs surgery technique to melanoma, this has not yet been fully approved by the majority of those doing Mohs surgery on a regular basis. There is some promising research. However, due in part to several factors, Mohs surgical technique is not routinely used for melanoma. Those factors include the simple fact that the morbidity and mortality (illness and fatality) statistics are not nearly as favorable with that disease. Also, processing the tissue demands additional technical help and delay and there are certainly limitations on analyzing the tissues beyond that of melanoma cells not contained in the outermost layer of the skin, the epidermis. Dr. Kivett attended a national meeting of the American College of Mohs Surgery and an electronic voting tally with many hundreds of practitioners in the room listed 22% of those in favor of using Mohs surgical technique and 78% against using that technique for very superficial melanomas.

One way to identify irregular moles that may try to become melanoma is to use the A through E rule. A is a lesion with an Asymmetrical (imbalanced) shape. B is a lesion with an irregular border, such as we see with scalloping, as opposed to smoothness. C is a lesion with more than one color. D is a lesion whose diameter is greater than that of a pencil eraser. E is a lesion that has evolved in shape, size or color over time.

One good suggestion for the skin, which is the largest organ of the body, is to have it photographed by someone at home. This would be done in a series of pictures that concentrate generally on a portion of a body surface. An example would be four photographs of the back, four of the face, four of the chest and abdomen, etc. A ruler would need to be placed in each photograph as a reference scale. This photo session would be done once in life. Then, on each birthday going forward, the original photographs would be brought up on a computer screen and then the lesions would be compared as to size and shape with the help of a ruler. Any lesions that were different in any way from the original photographs would be circled with a marker pen and then a skin specialist would look at those photographs with the patient in the room. Many of them of course would probably be unimportant but then an occasional lesion which had changed might be deemed to be worthy of a biopsy. This is a good mole monitoring technique because one cannot rely on oneself nor on family members to remember lesions and certainly the examining doctor from a year or two or three before could never be expected to remember and individual’s lesions.

In 1935 in Wisconsin, Dr. Mohs, with a young man’s goal of curing all kinds of cancer, began to study and treat cancerous tumors, first in animals. Then, as his methods improved, he began to treat patients who were otherwise relegated to a hospice status in an asylum for massively large skin cancers of the face, head and other areas, among other conditions. He began to discover, to everyone’s delight, that not only did he learn much more about the tumors, he ended up curing what were considered to be uncurable cancers. With that, he began to teach his techniques freely to any and all physicians who were so interested and he continued to do this throughout the length of his very long life.

Dr. Kivett was invited for a one year skin cancer fellowship in his UCLA professor’s private operative suites during the 1980 – 1981 time period, after several years’ training in San Francisco and at UCLA Medical Center. Later in that decade, Dr. Kivett worked with Dr. Mohs for a brief period and subsequently with some of Dr. Mohs’ long established former students, Drs. Stegman and Tromovitch in San Francisco. During his time with Dr. Mohs, Dr. Kivett deepened his knowledge of the removal of tumors from dozens of Dr. Mohs’ patients on a daily basis. Dr. Kivett also published with Dr. Mohs an article that he had composed which described the use of standardized visual diagrams to track tumors in the operating theater.

We Maximize Keeping Normal Skin Undisturbed During Mohs Surgery

Because skin cancer cells do not stick well together, they can be gently scraped after an equally gentle numbing process is used. The removal of the first layer of skin is very thin and allows preparation of a pathology slide for the surgeon to review in search of remaining cells. Only if more cells are seen under the microscope is another thin layer removed. Thus, tissue is not unnecessarily removed.

Skin cancer cells do not stick well together. This is because the connections between the cells, called desmosomes, are bonded together weakly, unlike regular skin, in which the cells are bonded together strongly. The human experience is one of having a shrink wrap protection for our body. This prevents leakage of protein-rich fluids and salts and prevention of the entry of bacteria, all of which maintain our health.

The process of removing the cancer starts after a typically well-tolerated numbing process with very gentle scraping with a half dull, tiny, slotted-spoon-shaped device called a curette. What is first produced is a small amount of a mush which represents the cancer cells. This mush is continuously swept aside until a resistant layer of skin is seen and felt.

What remains is mostly normal skin, which is where the process starts for the exploratory removal of one or more thin layers in less than three minutes for each layer. The removal of the first layer of skin (and possibly any remnants of tumor) is followed by preparation by a specialized tissue technician of a glass slide that is then studied under the microscope by the surgeon.

This removal is akin to an archaeologist placing strings for orientation over a pottery burial site and then slowly thinning down the soil in the search for more pottery. The strings are ways of marking zones on the ground, similar to MOHS surgeons making maps on paper and labeling them in a clock face or grid pattern. Once there’s no more pottery, then the process stops and the site is declared to be cleared.

This is similar to what Mohs surgeons do, until they find no more cancer under the microscope. Thus only the tiniest amount of skin is removed but with a high level of assurance that the cancer is gone. In order to qualify to be labeled as a Mohs surgery, the doctor reading the slide must also be the same doctor doing the tumor removal. Otherwise, the process is not qualified to be called Mohs surgery and cannot be represented to the patient or billed as such.

All this time, an hour or so, the patient who is still numb (for about three hours or so), waits nearby and has a snack and a drink and reads a book or chats in our reception area with another patient undergoing the same process.